MEDICAL    .SCHOOL 


dv  •    .laron  boriloss 
i^iemorial. 


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DEVELOPMENT  AND  ANATOMY 

OF  THE 

NASAL  ACCESSORY 
SINUSES 

IN  MAN 

Observations  Based  on  Two  Hundred  and 
Ninety  Lateral  Nasal  Walls,  Showing  the 
Various  Stages  and  Types  of  Development  of 
the  Accessory  Sinus  Areas  from  the  Sixtieth 
Day   of    Fetal    Life    to    Advanced    Maturity 

BY 

WARREN  B.  DAVIS,  M.D. 

CORINNA  BORDEN  KEEN  RESEARCH  FELLOW  OF  JEFFERSON 
MEDICAL  COLLEGE  ;  ASSISTANT  DEMONSTRATOR  OF  ANATOMY 
IN   THE  DANIEL   BAUGH  INSTITUTE  OF  ANATOMY,  PHILADELPHIA 


From   the  Laboratories  of  the  Friedrichshain   Krankenhaus,  Berlin, 
Germany,  and  the  Daniel  Baugh  Institute  of  Anatomy,  Philadelphia 


DRAWINGS  BY  DOROTHY  PETERS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1914 


Copyright,  1914,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


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FOREWORD 

The  literature  concerning  the  embryology,  later  develop- 
ment, and  adult  anatomy  of  the  nasal  accessory  sinuses 
is  rather  abundant,  yet  the  differences  in  the  views  expressed 
— especially  concerning  the  extent  of  development  during 
the  years  of  childhood — seemed  sufficiently  great  to  warrant 
further  study. 

The  author  therefore  has  collected  and  carefully  studied 
this  series  of  preparations  of  the  accessory  sinus  areas — 
which  series  covers  the  various  stages  of  development  from 
the  sixtieth  day  of  intrauterine  life  to  advanced  maturity — 
hoping  to  supply  information  regarding  some  few  points 
with  which  we  have  been  imperfectly  acquainted,  on  ac- 
count of  the  scarcity  of  specimens  showing  the  conditions 
present  during  the  years  of  childhood. 

Deductions  drawn  from  a  few  observations  are  open  to 
fallacy,  owing  to  variations  in  the  extent  and  type  of  de- 
velopment as  found  in  different  specimens  of  approximately 
the  same  age.  In  this  series  an  endeavor  has  been  made  to 
obtain  a  sufficient  number  of  cases  showing  the  various 
stages  of  development  to  make  the  general  averages  of  prac- 
tical value. 

The  bodies  of  children  between  the  ages  of  two  and  six- 
teen years  being  seldom  obtainable  in  the  dissecting  rooms 
of  European  institutions  as  well  as  in  America,  it  was  neces- 
sary, in  order  to  complete  such  a  series,  to  develop  a  technic 
by  which  the  accessory  sinus  areas  could  be  removed  en 

7 


.ii*182 


8  FOREWORD 

masse  at  the  time  of  postmortem  examinations,  and  still 
allow  reconstruction  of  the  face  without  marked  disfigure- 
ment. Ninety-six  of  the  cases  in  this  series  were  thus  ob- 
tained from  the  postmortem  room  of  the  Friedrichshain 
Krankenhaus,  Berlin,  for  which  privilege  and  for  courtesies 
shown  me  while  using  the  laboratories  of  that  institution 
I  wish  to  express  grateful  appreciation  to  Dr.  Ludwig 
Pick,  Professor  of  Pathology,  University  of  Berlin. 

The  material  for  the  other  post-natal  preparations  was 
furnished  by  the  Daniel  Baugh  Institute  of  Anatomy  of 
Philadelphia.  For  this  material,  for  laboratory  facilities, 
and  for  many  valuable  suggestions  regarding  the  work,  I 
am  under  obligations  to  Professor  Edward  Anthony  Spitzka, 
Dr.  H.  E.  Radasch,  and  Dr.  Howard  Dehoney. 

For  the  embryologic  and  fetal  material  I  wish  to  thank 
the  Gynecological  and  Obstetrical  Departments  of  Jeffer- 
son Medical  College,  also  Dr.  Wilhelm  Bode,  Assistant 
Pathologist  to  Friedrichshain  Krankenhaus. 

The  illustrations,  which  are  natural  size,  unless  other- 
wise stated  in  the  legends,  are  from  the  very  accurate  draw- 
ings made  by  Miss  Dorothy  Peters,  who  has  given  the  most 
careful  attention  to  detail. 

The  majority  of  the  dissections  will  be  permanently 
mounted  and  placed  in  the  museum  of  the  Daniel  Baugh 
Institute  of  Anatomy. 

Warren  B.  Davis 

1700  Walnut  Street,  Philadelphia. 
February,  1914- 


CONTENTS 

PAGE 

Foreword 7 

Anatomic  Material  Used 11 

Method  Used  in  Obtaining  and  Preparing  Specimens 15 

Embryologic  Considerations 19 

The  Cellule  Ethmoidales 44 

Cellule  Ethmoidales  Anterior 46 

Cellule  Ethmoidales  Posterior 77 

Cellule  Conchales 78 

The  Sinus  Maxillaris 79 

The  Sinus  Frontalis 132 

Supernumerary  Sinus  Frontales 146 

The  Form  and  Boundaries  of  the  Sinus  Frontalis 157 

The  Sinus  Sphenoidalis 160 

Bibliography 166 

Index 171 


THE  DEVELOPMENT  AND  ANATOMY  OF  THE 
NASAL  ACCESSORY  SINUSES  IN  MAN 


ANATOMIC  MATERIAL  USED 

The  anatomic  material  upon  which  the  observations  given 
in  this  report  are  based  consists  of  the  following  specimens: 

(a)  Serial  sections  for  microscopic  study  of  the  nasal 
areas  of  14  embryos  and  fetuses,  the  ages  of  which  were 
reckoned  as  closely  as  possible  by  estimates  based  upon  the 
measurements  of  total  length  (Diihrssen's  method),  and  also 
upon  length  from  vertex  to  buttocks.  The  ages  expressed 
in  days  of  embryonal  life  were  as  follows:  60,  63,  65,  85, 
91,  95,  98,  100,  115,  117,  118,  121,  126,  and  133  days. 

(6)  Sagittal  and  coronal  sections  for  macroscopic  study 
of  the  heads  of  8  fetuses,  aged  respectively  137,  139,  151,  188, 
196,  202,  224,  and  246  days. 

(c)  Sagittal  and  horizontal  sections  of  the  heads  of  4 
full-term  fetuses. 

(d)  Sagittal,  coronal,  and  horizontal  sections  of  the  nasal 
and  accessory  sinus  areas  of  101  postnatal  heads,  the  mucosa 
remaining  intact  in  each  case.  The  exact  ages  of  cases  from 
which  specimens  were  obtained  are  given  in  the  following 
table : 


Series  D 

Age 

Sex 

Plane  op  Sections 

Case  Number 
1 

2 

3 

4 

Years 

Months 

*i 

3 

4 

Days 

8 

8 

15 

Female 

Male 

(I 

Female 

Sagittal 
Coronal 

u 

Horizontal 

11 


12 


THE   NASAL   ACCESSORY   SINUSES   IN   MAN 


Series  D 

Age 

Sex 

Plane  of  Sections 

Case  Number 

Years 

Months 

Days 

5 

4 

27 

Male 

Sagittal 

6 

5 

u 

Horizontal 

7 

6 

is 

Female 

Coronal 

8 

8 

Male 

Sagittal 

9 

10 

(( 

<( 

10 

10 

6 

ti 

Coronal 

11 

4 

(( 

u 

12 

2 

3 

Female 

« 

13 

2 

15 

i< 

Sagittal 

14 

4 

7 

Male 

u 

15 

6 

6 

(( 

Coronal 

16 

7 

26 

u 

Sagittal 

17 

8 

1 

(( 

Coronal 

18 

8 

14 

Female 

Horizontal 

19 

9 

Male 

Coronal 

20 

10 

13 

Female 

Sagittal 

21 

2 

14 

Male 

" 

22 

2 

3 

" 

(t 

23 

2 

5 

20 

'< 

Coronal 

24 

2 

6 

7 

u 

u 

25 

2 

6 

12 

Female 

Sagittal 

26 

2 

7 

8 

a 

ii 

27 

2 

8 

24 

Male 

11 

28 

2 

11 

21 

" 

Coronal 

29 

3 

2 

Female 

Horizontal 

30 

3 

4 

6 

a 

Coronal 

31 

3 

4 

6 

(( 

Sagittal 

32 

3 

5 

8 

Male 

Coronal 

33 

3 

9 

10 

(( 

Sagittal 

34 

3 

11 

Female 

" 

35 

4 

5 

(( 

a 

36 

4 

2 

Male 

Coronal 

37 

4 

3 

2 

" 

Sagittal 

38 

4 

3 

5 

Female 

a 

39 

4 

6 

8 

Male 

Coronal 

40 

4 

7 

19 

u 

u 

41 

4 

10 

4 

" 

42 

4 

10 

5 

Female 

Sagittal 

43 

5 

17 

u 

Coronal 

44 

5 

6 

3 

Male 

Sagittal 

45 

5 

10 

22 

a 

" 

46 

6 

u 

(< 

47 

6 

1 

Female 

11 

48 

6 

2 

Male 

49 

6 

6 

15 

Female 

50 

6 

7 

7 

(I 

Coronal 

51 

6 

8 

28 

Male 

Sagittal 

52 

6 

9 

24 

Female 

Coronal 

53 

6 

10 

20 

Male 

Sagittal 

54 

7 

1 

Female 

" 

55 

7 

2 

2 

Male 

(( 

56 

7 

6 

4 

Female 

<< 

ANATOMIC   MATERIAL   USED 


13 


Series  D 

Age 

Sex 

Plane  op  Sections 

Case  Number 

Years 

Months           D 

ays 

57 

7 

7             2 

0             Female 

Coronal 

58 

7 

9             1 

2 

" 

59 

8 

2             1 

0              Male 

Sagittal 

60 

8 

2             1 

2 

" 

61 

8 

2              2 

5              Female 

a 

62 

8 

7 

3       !       Male 

Coronal 

63 

8 

8 

1             Female 

Sagittal 

64 

9 

1 

9 

65 .. 

9 

10             1 

9       I       Male 

Coronal 

66 

10 

1 

7 

Sagittal 

67 

10 

7             2 

!7 

u 

68 

11 

Female 

11 

69 

12 

9              1 

2             Male 

Coronal 

70 

13 

" 

Sagittal 

71 . 

13 

2 

8 

(I 

72 

13 

6             1 

9 

Coronal 

73 

14 

7 

Female 

Sagittal 

74 

15 

Male 

Horizontal 

75 

15 

5 

u 

Coronal 

76. 

15 

9             2 

56 

Sagittal 

77 

16 

it 

Horizontal 

78 

16 

2             ] 

7 

Sagittal 

79 

16 

5             2 

51              Female 

80 

16 

8 

2 

Coronal 

81 

17 

Male 

Sagittal 

82 

17 

u 

Coronal 

83 

17 

ii 

Sagittal 

84 

17 

11 

Female 

it 

85 

18 

11              ] 

LO             Male 

et 

86 

19 

>8              Female 

it 

87 

19 

6             ] 

[5             Male 

it 

88 

19 

7             ] 

L5              Female 

it 

89 

20 

Male 

" 

90 

20 

5 

Female 

Coronal 

91 

21 

6             ^ 

J9 

Sagittal 

92 

22 

ii 

93 

22 

6             ] 

Li 

it 

94 

23 

7             ] 

L3             Male 

it 

95 

25 

" 

it 

96 

25 

3 

Female 

a 

97 

28 

Male 

it 

98 

50 

" 

it 

99 

56 

Female 

" 

100 

62 

Male 

" 

101 

68 

1 

Female 

" 

Males  ...  59 

Sagittal 64 

Females  .  42 

Coronal 31 

Horizontal 6 

(e)  Eighteen  macerated  skulls  were  prepared  for  study 


14  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

by  sectioning  in  the  various  planes,  the  majority  being  hori- 
zontal. The  skulls  were  evidently  those  of  middle-aged 
individuals,  but  the  exact  ages  could  not  be  obtained. 

Thus  the  total  number  of  cases  studied  was  145,  or  290 
lateral  nasal  walls  and  accessory  sinus  areas.  The  speci- 
mens in  each  case  were  prepared  by  sectioning  and  dissecting, 
so  that  the  nasal  cavities  and  all  accessory  sinuses  on  each 
side  could  be  thoroughly  examined. 


METHODS  USED  IN  OBTAINING  AND  PREPARING 
SPECIMENS 

(a)  Method  Used  in  Removing  the  Nasal  Accessory- 
Sinus  Areas  en  Masse  at  Postmortem  Examinations  With- 
out Producing  Marked  Disfigurement  of  the  Face. — The 
skull  having  been  opened  by  the  usual  circumferential  saw- 
cut  and  the  brain  removed,  further  detach  the  skin  and  sub- 
cutaneous structures  from  the  frontal  area  to  the  level  of 
the  nasion.  With  the  saw  make  in  the  sagittal  direction 
cuts  through  the  frontal  bone  just  lateral  to  each  supra- 
orbital notch,  and  extending  through  the  supra-orbital 
plates.  Remove  with  bone-forceps  the  portion  of  supra- 
orbital plates  lying  lateral  to  the  sagittal  cuts,  thus  obtaining 
room  to  detach  the  eyeballs  posteriorly  and  turn  them  for- 
ward. Dissect  the  skin  and  muscles  from  the  nasal,  lacrimal, 
and  maxillary  bones;  then  from  the  anterior  end  of  the  nasal 
bones  cut  through  the  nasal  septum  and  lateral  nasal 
cartilages  to  the  anterior  nasal  spine  of  the  maxilla.  With 
a  chisel  cut  through  the  basi-occipital  bone;  thence  lateral 
to  the  body  of  the  sphenoid  extend  the  cuts  to  the  spheno- 
maxillary fissure.  With  a  saw  or  with  a  costotome  cut 
through  the  maxillary  processes  of  the  malar  bones  and 
remove  the  specimen  en  masse. 

To  reconstruct  the  face,  fill  the  oral  cavity  and  the  space 
previously  occupied  by  the  specimen  with  cotton  packed 
firmly  to  the  level  of  the  orbital  floor.  Turn  the  eyeballs 
back  into  place,  and  pass  two  sutures  through  the  sub- 

15 


16  THE   NASAL   ACCESSORY   SINUSES   IN   MAN 

cutaneous  structures  just  posterior  to  the  inner  canthi,  and 
tighten  them  until  the  eyes  are  held  the  proper  distance  apart. 
Pack  cotton  anterior  to  these  sutures  to  form  a  bridge 
for  the  nose,  and  by  pressure  and  adjustment  of  position  of 
cotton  mold  the  nose  into  its  original  shape.  Fill  the  re- 
maining portion  of  the  cranial  cavity  with  cotton  or  oakum 
and  make  the  interfrontal  area  smooth  and  firm  by  means  of 
plaster-of -Paris.     Replace  the  calvarium  in  the  usual  way. 

The  above-described  method  was  devised  by  the  author 
for  obtaining  anatomic  and  pathologic  specimens  from  cases 
in  which  it  was  necessary  to  avoid  undue  disfigurement  of 
the  face.  The  majority  of  the  figures  illustrating  this  work 
were  drawn  from  specimens  obtained  in  this  manner  from 
the  postmortem  rooms  of  Friedrichshain  Krankenhaus, 
Berlin.  In  only  one  out  of  97  cases  was  the  disfigurement 
sufficient  to  cause  criticism  or  dissatisfaction  on  the  part  of 
parents  or  other  relatives  of  the  individuals.  In  that  case 
it  was  necessary  to  replace  the  specimen. 

(6)  Methods  Used  in  Preparing  Specimens. — 1.  Serial 
sections  for  microscopic  study  were  made  of  the  youngest 
14  embryos  and  fetuses  of  the  series.  Specimens  were  fixed 
in  10  per  cent,  formalin.  Those  in  which  ossification  had 
advanced  sufficiently  to  interfere  with  sectioning  with 
microtome  were  decalcified  in  a  solution  of  10  per  cent, 
nitric  acid  in  4  per  cent,  formalin.  The  usual  technic  for 
celloidin  infiltration  and  blocking  was  used  in  9  cases  and  the 
paraffin  method  in  the  remaining  5.  The  celloidin  sections 
were  more  satisfactory.  Hematoxylin  and  eosin  staining 
was  used  for  all  sections. 

2.  The  heads  of  fetuses  prepared  for  macroscopic  study 
and  the  96  postnatal  specimens  from  Friedrichshain  Krank- 


METHODS  USED  IN  OBTAINING  AND  PREPARING  SPECIMENS    17 

enhaus  were  placed  in  10  per  cent  formalin  immediately 
after  removal  from  the  bodies  and  allowed  to  harden  in  this 
solution  for  a  period  of  from  eight  to  ten  weeks,  at  the  end  of 
which  time  they  were  sectioned  in  the  desired  plane  by  means 
of  very  small,  narrow  saws.  Jewelers'  saws  were  used  for 
sectioning  through  the  teeth,  and  small  scroll  saws  were 
used  for  other  parts.  The  mucosa  remained  perfectly 
attached  in  nearly  all  instances,  and  in  no  case  were  the 
relations  of  the  dehcate  bones  of  the  ethmoid  areas  disturbed. 

3.  In  5  cases  frozen  sections  were  made  at  various  levels 
in  the  horizontal  plane. 

4.  In  the  18  skulls  from  which  the  soft  parts  had  been 
removed  by  maceration  all  accessory  sinus  areas  were  com- 
pletely filled  with  paraffin  before  sectioning  with  a  thin  saw, 
thus  avoiding  fractures  of  the  delicate  plates  of  bone  in  the 
ethmoid  area.  The  paraffin  was  removed  by  placing  the 
specimens  in  hot  water.  This  method  is  of  great  value  in 
obtaining  nearly  perfect  bony  specimens. 

The  ostia  of  the  accessory  sinuses,  however,  can  be  ac- 
curately studied  as  to  size,  location,  and  exact  communi- 
cations only  when  the  mucosa  is  intact.  Thus  these  18 
osseous  specimens  were  used  only  in  the  study  of  size,  ex- 
tent, and  relations  of  the  sinus  cavities  and  their  walls,  and 
were  not  included  in  any  of  the  estimations  regarding  the 
ostia. 

From  the  previously  given  lists  it  is  seen  that  the  stages 
of  development  shown  by  these  preparations  form  a  con- 
tinuous series  from  the  sixtieth  day  of  intra-uterine  life  up 
to  maturity,  and  then  a  few  specimens  from  the  aged. 

The  development  of  the  nasal  areas  earlier  than  the 
sixtieth  day  of  embryonal  life  will  be  considered  only  in  the 
2 


1*8  THE   NASAL   ACCESSORY   SINUSES   IN   MAN 

form  of  a  brief  summary,  expressing  the  consensus  of  opinions 
held  by  embryologic  observers.  The  statements  regarding 
the  development  later  than  the  sixtieth  day  of  embryonal 
life  are  based  upon  conditions  as  shown  in  this  series,  unless 
otherwise  stated. 


EMBRYOLOGIC  CONSIDERATIONS 

During  the  third  week  of  embryonal  hfe  there  is  evidence 
of  beginning  development  of  the  nasal  areas  as  shown  by 
increasing  thickness  of  the  ectoderm  on  the  anterolateral 
portions  of  the  forebrain.  At  the  end  of  the  third  week,  or 
during  the  fourth  week,  the  nasal  area  appears  as  a  depression 
which  is  brought  about  by  the  increased  thickness  of  the 
surrounding  mesenchyme.  In  the  mesenchyme  investing 
the  anterior  portion  of  the  notochord  is  the  first  appearance 
of  the  primordial  cranium;  this  then  extends  dorsally  to 
inclose  the  anterior  portion  of  the  medullary  canal,  which 
will  later  become  the  cerebral  part  of  the  central  nervous 
system.  The  primitive  nasal  capsule  develops  as  a  part  of 
the  primordial  cranium.  From  that  part  which  extends 
forward  beyond  the  anterior  portion  of  the  notochord  a  core 
is  formed  for  the  frontonasal  process — a  relatively  broad 
mass  of  tissue  separating  the  nasal  pits.  The  nasal  pits  are 
symmetric  depressions,  at  first  pyriform  in  outline,  with 
the  small  ends  toward  the  primitive  mouth  cavity.  As  the 
processus  globularis  on  the  lateral  portion  of  the  medial 
nasal  process  approximates  the  lateral  nasal  and  maxillary 
processes,  there  is  a  deepening  of  the  primitive  nasal  fossae 
and  a  change  in  their  form,  which  becomes  oval  and  bordered 
by  broad  folds.  The  broad  median  process  separating  the 
depressions  later  becomes  narrowed  and  forms  the  septum 
nasi.  By  the  approximation  of  the  nasal  processes  inferiorly, 
their  ectodermal  coverings  are  brought  into  contact.     The 

19 


20  THE    NASAL   ACCESSORY   SINUSES    IN   MAN 

intervening  ectoderm  is  resorbed,  and  the  processes  become 
united  by  mesoderm,  which  forms  the  floor  of  the  primitive 
anterior  nares.  In  the  fifth  week,  or  shortly  thereafter,  by 
the  partial  resorption  of  ectodermal  cells  filhng  the  reniain- 
ing  interspaces  between  the  median  and  lateral  nasal  proc- 
esses, there  is  formed  behind  the  os  intermaxillare  the 
primitive  ductus  nasopharyngeus.  Posteriorly,  there  per- 
sist for  a  short  while  the  membranse  bucconasales,  which 
break  through  and  form  the  primitive  choanse  at  a  time 
somewhere  be  ween  the  twenty-eighth  and  fortieth  day — the 
observations  of  the  different  embryologists  varying  to  that 
extent. 

The  basal  part  of  the  primordial  cranium  develops  into 
chondrocranium.  Laterally,  the  basal  plates  develop  as  the 
periotic  capsules;  ventrally  they  form  the  mesethmoid 
plate  (from  the  lower  portion  of  which  the  vomer  later 
develops),  and  anterolaterally  they  enter  into  the  formation 
of  the  nasal  capsule.  In  the  second  month  the  nasal  capsule 
becomes  clearly  differentiated  from  other  mesoderm  and 
shows  beginning  cartilaginous  development. 

The  palatal  ridges  appear  on  the  medial  sides  of  the 
maxillary  processes  from  the  forty-fifth  to  forty-eighth  day 
of  embryonal  life  (J.  P.  Schaeffer),  and  by  their  approxima- 
tion the  palate  is  formed. 

Concerning  the  early  development  of  the  conchse,  Schaeffer 
records  in  his  very  thorough  studies  of  the  embryologic 
development  of  the  lateral  nasal  wall  that  the  concha 
nasalis  inferior  appears  in  embryos  of  thirty-eight  to  forty 
days  as  a  bulging  of  the  inferior  portion  of  the  lateral  nasal 
wall  immediately  superior  to  the  portion  from  which  the 
palatal  processes  develop.     From  the  fortieth  to  the  forty- 


EMBRYOLOGIC    CONSIDERATIONS 


21 


Ca.rt.ca.p-na.. 


-EpitKeliail  jAv^ 


-Procaa-frorvt 


-Ld.b.  sup. 


Fig.  1. — Diagram  Drawn  From  a  Coronal  Section  Through  Anterior 
Portion  of  Nasal  Area  of  a  Sixty-day  Embryo.  (Series  A,  No.  1,  slide 
2,  section  4.     X  16%.) 

Cart. cap. na.,  Cartilage  capsulse  nasalis,  showing  the  portion  which  later 
forms  the  anterior  extremity  of  the  nasal  bone;  Epithelial  plug,  a  mass  of  epi- 
thelial cells  completely  filling  the  anterior  naris;  Proc.na. front.,  antero-inferior 
portion  of  the  processus  nasofrontalis;  Lab. sup.,  labium  supeiius. 


C&.rt.caup.na.. 


C.  j,n,t 


^Sept  aa.. 


Fig.  2. — Diagram  Drawn  From  a  Coronal  Section,  0.82  mm.  Posterior  to 

THAT  Shown  in  Fig.  1.     (Series  A,  No.  1,  sHde  4,  section  12.     X  16%.) 
Cart.cap.na.,  Cartilago  capsulae  nasalis;  Sept.na.,  septum  nasi;  C.inf.,  concha 

inferior. 


EMBRYOLOGIC    CONSIDERATIONS 


23 


Ca.Tt.ca.p  a 


^ W    H 


Lingua. 


Fig.  3. — Diagram  Drawn  From  a  Coronal  Section  Through  Nasal  Area 

OF  A  Sixty-day  Embryo,  0.45  mm.  Posterior  to  the  Section  Shown  in 

Fig.  2.     (Series  A,  No.  1,  slide  6,  section  6.     X  16%.) 

Sept.na.,  Septum  nasi;  note  relative  thickness  at  this  stage  of  development; 

C.inf.,  concha  inferior;    Proc.pal.,  processus  palatinus  of  maxilla;    Org.vom., 

organon  vomeronasale  (Jacobsoni);    Cart.cap.na.,  cartilage  capsulse  nasalis. 


Fig.  4. — Diagram  Drawn  From  a  Coronal  Section  Through  Nasal  Area 
OF  A  Sixty-day  Embryo,  0.25  mm.  Posterior  to  Section  Shown  in  Fig.  3. 
(Series  A,  No.  1,  slide  7,  section  4.      X  16%.) 

C.med.,  Concha  media  (note  that  cartilage  has  not  yet  developed  in  this 
portion  of  concha);  C.inf.,  concha  inferior;  Proc.pal.,  processus  palatinus  of 
maxilla;   Sept.na.,  septum  nasi;   Cart.cap.na.,  cartilago  capsulse  nasalis. 


EMBRYOLOGIC    CONSIDERATIONS  25 

third  day  the  ethmoidal  fold  appears  superior  and  slightly 
dorsal  to  the  fold  representing  the  concha  inferior,  and  from 
this  ethmoidal  fold  the  ethmoidal  conchse  are  developed  as 
the  nasal  cavity  increases  in  its  supero-inferior  diameter. 

Coming  now  to  the  conditions  shown  in  the  sixty-day 
embryo  (the  youngest  studied  in  this  series),  we  find  the 
cartilaginous  development  in  the  nasal  capsule  well  ad- 
vanced. The  anterior  nares  are  filled  by  the  masses  of 
epithelial  cells  (Fig.  1),  a  condition  persisting  in  some 
specimens  up  to  one  hundred  and  fifteen  days.  The  lateral 
nasal  wall  shows  two  distinct  folds  (Fig.  4),  the  lower  being 
the  concha  nasalis  inferior  and  the  superior  one  the  ethmoidal 
fold,  which  is  beginning  to  assume  the  form  of  the  concha 
nasalis  media.  In  its  posterosuperior  portion,  the  ethmoidal 
fold  shows  a  further  differentiation,  indicating  the  early 
formation  of  the  concha  superior  (Fig.  5).  The  conchse, 
in  their  earlier  stages  of  development,  do  not  contain  car- 
tilage, but  are  folds  of  mesenchyme  covered  by  nasal  epi- 
thelium. In  the  sixty-day  embryos  (Figs.  1-5)  the  central 
portion  of  the  concha  inferior  and  the  concha  media  shows 
condensation  of  the  mesenchyme  and  its  transformation 
into  cartilage.  In  the  concha  superior,  however,  cartilagin- 
ous development  has  not  yet  begun.  As  the  central  por- 
tion of  the  mesenchyme  entering  into  the  formation  of  the 
conchse  becomes  more  dense  and  is  transformed  into  carti- 
laginous structures,  it  appears  as  an  extension  of  or  a  pro- 
jection from  the  cartilage  forming  the  lateral  portion  of  the 
nasal  capsule. 

As  the  conchse  become  more  prominent  medially,  there  is 
also  a  lateral  deepening  of  the  grooves  immediately  beneath 


26  THE   NASAL   ACCESSORY   SINUSES   IN   MAN 

the  conchse,  each  groove  becoming  a  meatus  which  is  named 
in  accordance  with  the  concha  beneath  which  it  hes. 

A  sixty-day  fetus  further  shows  on  the  anterosuperior 
portion  of  the  lateral  nasal  wall,  just  anterior  to  the  eth- 
moidal fold,  a  smaller  prominence  representing  the  early 
formation  of  the  agger  nasi  or  nasoturbinal.  From  the 
posterior  portion  of  the  agger  nasi  there  is  seen  in  the  sixty- 
five-day  embryo  (Fig.  6)  a  ridge  of  mesenchyme  extending 
in  a  postero-inferior  direction  along  the  superior  curved 
border  of  the  concha  inferior. 

This  ridge,  which  has  its  free  edge  directed  postero- 
superiorly  and  slightly  medially,  is  the  early  processus  un- 
cinatus,  in  which  there  soon  appears  a  thickening  or  con- 
densation of  the  mesoderm  in  its  central  portion,  followed 
by  transformation  into  cartilage  (Fig.  9).  The  agger  nasi 
with  the  processus  uncinatus  together  form  the  "Erste 
Hauptmuschel"  of  Killian.  However,  in  this  work  it  will 
not  be  listed  as  one  of  the  conchae,  for,  although  comparative 
anatomy  shows  these  structures  to  be  the  homologue  of  the 
inferior  olfactory  concha  as  found  in  lower  mammalia,  yet 
the  form  and  position  which  they  have  assumed  in  the  human 
type  are  such  that  we  deem  it  best  not  to  consider  them 
as  forming  one  of  the  true  nasal  conchae. 

Shortly  after  the  appearance  of  the  processus  uncinatus 
there  is  seen,  just  inferior  to  the  attachment  of  the  middle 
portion  of  the  concha  media,  another  projection,  which  also 
develops  from  the  lateral  nasal  wall,  with  its  free  border 
facing  in  an  antero-inferior  and  slightly  medial  direction 
(Fig.  9).  This  fold  is  the  early  bulla  ethmoidalis,  which 
develops  from  the  lateral  ethmoidal  mass  as  one  of  its  sec- 
ondary folds. 


EMBRYOLOGIC    CONSIDERATIONS 


27 


v^ 


Fig.  o. — Diagram  Drawn  From  a  Coronal  Section,  0.97  mm.  Posterior  to 
THAT  Shown  in  Fig.  4.     (Series  A,  No.  1,  slide  10,  section  6.     X  16%.) 
Cart.cap.na.,    Cartilage    capsulse    nasalis;    C.sup.,   concha  superior   (note 

that   at   this   stage   of   development   there  is  no  cartilage   in  this  concha); 

C.med.,  concha  media;   C.inf.,  concha  inferior. 


Itviund.etK 


^^ 


Fig.  6. — Diagram  Drawn  From  Coronal  Section  Through  Anterior 
Third  of  Nasal  Area  of  a  Sixty-five-day  Embryo,  Showing  the  De- 
velopment OF  the  Processus  Uncinatus,  Which  at  This  Period  Ap- 
pears AS  A  Ridge  Along  the  Superior  Curved  Border  of  the  Concha 
Inferior.     (Series  A,  No.  3,  slide  5,  section  11.     X  16.) 

C.med.,  Concha  media;  Sept.na.,  septum  nasi;  C.inf.,  concha  inferior;  In- 
fund.eth.,  infundibulum  ethmoidale;   Proc.unc,  processus  uncinatus. 


EMBRYOLOGIC    CONSIDERATIONS 


29 


C^up. 


^  ^-Z 


<;d-rt.cd.p.r\d.. 


^  ''"''"S Sent.  "a. 


Fig.  7. — Diagram  of  Coronal  Section  Through  Nasal  Area,  0.45  mm. 
Dorsal  to  Section  Shown  in  Fig.  6,  Showing  Relations  of  Developing 
Concha.  Concha  Superior  Shows  in  its  Central  Area  a  Thickening 
OF  the  Mesoderm  Which  Later  Becomes  Cartilage.  (Series  A,  No.  3, 
slide  7,  section  3.     X  16.) 

Cartxap.na.,  Cartilage  capsulae  nasalis;  *Sep^.na.,  septum  nasi;  C.inf.,  concha 
inferior;  C.med.,  concha  media;  C.sup.,  concha  superior. 


EMBRYOLOGIC    CONSIDERATIONS 


31 


C.a,rt.ca-p.na.. 

Sept.  na. 


^Orblt. 


CKoa.n.aL,e,. 


Fig.  8. — Diagram  Drawn  From  a  Coronal  Section  Just  Posterior  to 
THE  Recessus  Spheno-ethmoidalis,  Showing  the  Primitive  Sinus  Sphe- 

NOIDALES   which   DeVELOP   AS   INVAGINATIONS   OF    MuCOSA   INTO   THE    POS- 
TERIOR Nasal  Capsule.     (Series  A,  No.  3  (sixty-five-day  embryo),  slide  10, 
section  10.     X  16.) 
S.sph.,  Sinus  sphenoidales;    Cart. cap. na.,  cartilage  capsulae  nasalis;   Sept.na., 

septum  nasi. 


EMBRYOLOGIC    CONSIDERATIONS 


33 


Cmec- 


FiG.  9. — Diagram  of  Coronal  Section  Through  the  Anterior  Third  op 
THE  Nasal  Area  of  a  Ninty-five-day  Embryo,  to  Show  the  Extent 
OF  [Development  and  Relations  of  the  Processus  Uncinatus  and 
THE  Bulla  Ethmoidalis.  (Series  A,  No.  6,  slide  11,  section  6.  X  10.) 
Cr.gal.,  Crista  galli;  B.eth.,  bulla  ethmoidalis;  Proc.unc,  processus  un- 
cinatus; Infund.eth.,  infundibulum  ethmoidale;  C.inf.,  concha  inferior; 
C.med.,  concha  media;  Sept.na.,  septum  nasi. 


EMBRYOLOGIC    CONSIDERATIONS  35 

Between  the  free  antero-inferior  surface  of  the  bulla  and 
the  posterosuperior  surface  of  the  processus  uncinatus  is  a 
narrow  interval,  the  primitive  hiatus  semilunaris,  which  is 
the  opening  or  means  of  communication  between  the  meatus 
medius  and  the  infundibulum  ethmoidale,  the  infundibulum 
developing  as  the  gutter-like  channel  lateral  to  the  processus 
uncinatus  (Figs.  9,  12,  and  14).  It  is  these  structures  which 
make  the  lateral  wall  of  the  meatus  medius  rather  compli- 
cated. Their  variations  in  form  and  type  of  development 
give  rise  to  different  locations  of  the  ostia  of  the  anterior 
ethmoidal  cells,  and  thus  influence  the  manner  in  which  the 
frontal  sinus  communicates  with  the  middle  meatus. 

The  bulla  ethmoidalis  in  some  instances  appears  as  a 
smooth  bulging  fold  in  which  the  cartilage,  developing  as  an 
extension  from  the  lateral  nasal  capsule,  is  evenly  rounded 
in  its  outline, — thus  making  a  single  oval  fold  (Fig.  9).  In 
other  cases  the  cartilage  shows  a  double  fold  or  a  deep  groove 
in  the  single  fold,  and  in  some  instances  two  such  grooves 
are  seen  (Fig.  12).  Evidence  of  this  type  of  formation  is 
sometimes  seen  in  early  childhood  as  a  slight  groove  in  the 
overlying  mucosa  along  the  middle  portion  of  the  bulla, 
but  in  no  case  did  we  find  the  ostium  of  a  bullar  cell  located 
so  as  to  indicate  that  it  had  its  origin  in  such  a  furrow. 

The  number  of  ethmoidal  conchse  into  which  the  lateral 
ethmoidal  mass  becomes  differentiated  varies  from  three  to 
five.  The  majority  of  fetuses  examined  had  three  ethmoidal 
conchse — four  were  not  uncommonly  present;  but  only  on 
one  side  of  one  specimen  were  five  demonstrable  (Fig.  16). 
Killian  would  count  such  a  specimen  as  having  six  ethmoidal 
conchse,  since  he  counts  the  agger  nasi  plus  the  processus 
uncinatus  as  the  first  ethmoidal  concha, — ^'Erste  Haupt- 


36  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

muschel," — and  believes  that  such  a  condition  represents 
the  typical  number  of  conchae  originally  possessed  by  all 
ethmoidal  areas  at  some  time  in  early  fetal  life.  He  con- 
cludes, therefore,  that  specimens  showing  fewer  conchae 
do  so  because  of  the  fusing  of  two  or  more  of  the 
primitive  ethmoidal  folds.  However,  since  his  own  large 
series  of  fetuses  showed  only  two  specimens  in  which  so 
many  conchae  were  distinctly  differentiated,  and  since  such 
specimens  are  so  seldom  found  by  other  observers  of  embryo- 
logic  and  fetal  conditions,  it  seems  more  probable  that  the 
number  found  in  any  given  case  depends  more  upon  the 
extent  to  which  differentiation  was  carried  than  it  does  upon 
the  fusing  of  conchae  already  formed.  Zuckerkandl  gives 
three  ethmoidal  conchae  as  the  typical  number,  but  found 
four  present  in  6.7  per  cent,  of  cases.  Seydel  found  no  speci- 
mens showing  more  than  three,  while  Schaeffer  found  four 
to  be  rather  common.  E.  Kellius  believed  the  development 
of  five  to  be  very  seldom.  The  nomenclature  for  the  conchae 
nasales  should  be  applicable  to  adult  conditions  and  also 
cover  the  highest  number  found  in  fetal  life  (Fig.  16).  This 
is  satisfactorily  done  by  the  terms  used  by  Schaeffer,  which 
are  as  follows: 

Concha  nasalis  inferior 
media 
superior 
suprema  I 
suprema  H 
suprema  III 

The  meatus  beneath  each  concha  is  similarly  designated. 
In  my  own  series  of  202  postnatal  lateral  nasal  walls  having 


EMBRYOLOGIC    CONSIDERATIONS 


37 


C.  sup. 


C.lnf 


Fig.  10. — Diagram  Drawn  From  a  Coronal  Section  Through  the  Middle 
Third  of  the  Nasal  Area  of  a  One-hundred-day  Embryo.  (Series  A, 
No.  8,  slide  14,  section  4.      X  10.) 

Sept.na.,  Septum  nasi;  C.acces.,  concha  accessoria,  a  fold  which  bears  a 
relation  to  the  meatus  superior  somewhat  similar  to  that  which  the  bulla 
ethmoidalis  bears  to  the  meatus  medius.  The  concha  accessoria,  however, 
is  not  always  so  distinctly  marked.  B.eth.,  posterior  end  of  bulla  ethmoidalis; 
C.inf.,  concha  inferior;  C.med.,  concha  media  (note  the  inferior  and  medial 
grooves  in  the  cartilage  of  this  concha);  C.sup.,  concha  superior. 


EMBRYOLOGIC    CONSIDERATIONS 


39 


CaLrt.co.pkn.a„ 


Ost.SpH. 


Sept.-nA^ 


Fig.  11. — Diagram  Drawn  From  a  Coronal  Section  Just  Dorsal  to  the 
Recessus  Spheno-ethmoidalis  of  a  One-hundred-day  Embryo,  Showing 
THE  Development  of  the  Sinus  Sphenoidales  into  the  Posterior  Por- 
tion OF  THE  Cartilaginous  Nasal  Capsule.  (Series  A,  No.  8,  slide  18, 
section  6.  X  10.) 
Cart. cap. na.,  Cartilage  capsulse  nasalis,  posterior  portion;    Ost.sph.,  ostium 

sphenoidale;  Sept.na.,  septum  nasi,  most  posterior  portion;  Pal.moL,  palatum 

molle. 


EMBRYOLOGIC    CONSIDERATIONS 


41 


1  rxf  ur\d   e  tK 


Frocun-c, 


Fig.  12. — Diagram  Drawn  From  a  Coronal  Section  Near  theJMidpoint 
Anteroposteriorly  of  the  Lateral  Nasal  Wall.     (Series  A,  No.  12 
(one-hundred-and-twenty-one-day  fetus),  slide  8,  section  1.     X  6.) 
B.eth.,   Bulla  ethmoidalis;     C.med.,   concha  media;     Proc.unc,   processus 

uncinatus;    C.inf.,   concha  inferior;    Infund.eth.,   infundibulum  ethmoidale; 

Sept.na.,  septum  nasi. 


EMBRYOLOGIC    CONSIDERATIONS  43 

mucosa  attached,  four  ethmoidal  conchae  were  present  in 
2  per  cent,  of  the  cases,  three  in  92  per  cent.,  and  two  in 
only  6  per  cent.,  yet  two  is  the  number  most  frequently 
described  in  anatomic  works. 

All  ethmoidal  cells,  the  frontal  and  maxillary  sinuses, 
have  their  origin  from  preformed  grooves  or  furrows  between 
the  folds  which  develop  on  the  lateral  nasal  wall.  The 
meatus  nasi  medius  soon  becomes  the  most  complex  portion 
of  the  nasal  cavity,  and  developing  from  it  and  extending 
into  the  surrounding  areas  are  extensive  processes  of  pneu- 
matization  which  are  termed  the  cellulse  ethmoidales  anterior, 
the  sinus  maxillaris,  and  the  sinus  frontalis. 


THE  CELLULE  ETHMOIDALES 

The  cellulse  ethmoidales  are  often  considered  as  forming 
anterior,  middle,  and  posterior  groups  of  cells.  However, 
we  believe  a  classification  more  satisfactory  from  an  anatomic 
viewpoint,  and  more  practical  from  the  clinical  aspect  to  be 
one  which  divides  them  primarily  into  anterior  and  pos- 
terior groups,  each  of  which  is  further  subdivided. 

All  ethmoidal  cells  having  their  ostia  inferior  to  the 
attachment  of  the  concha  nasalis  media  belong  to  the  an- 
terior group,  while  those  having  their  ostia  superior  to  the 
concha  media  belong  to  the  posterior  group  (Fig.  43).  This 
classification  holds  good  regardless  of  how  far  the  more  dis- 
tant portions  of  any  irregularly  developed  cell  of  either  group 
may  invade  the  region  ordinarily  occupied  by  cells  of  the 
other  group.  In  considering  the  cells  entering  into  the 
formation  of  these  two  primary  groups  the  following  classi- 
fication will  be  used: 

Cellulse  frontales. 
Cellulse  ethmoidales  anterior:    \  Cellulse  infundibulares. 

Cellulse  bullae  ethmoidales. 


Cellulse  ethmoidales  posterior : 


Cells  communicating  with 
the  meatus  superior. 

Cells  communicating   with 
the  meatus  supremus  I. 

Cells   communicating  with 
the  meatus  supremus  II. 


44 


THE    CELLULE    ETHMOIDALES  45 

Seydel  observed  that  an  ethmoid  cell,  having  its  origin 
from  any  given  meatus,  did  not  communicate  with  any  cell 
having  its  origin  from  any  other  meatus.  Zuckerkandl 
took  exception  to  this  statement,  but  certainly  every  speci- 
men in  this  series  supports  Seydel' s  view. 


DEVELOPMENT  OF  THE  CELLULJE  ETHMOIDALES 

In  the  latter  part  of  the  third  month  of  intra-uterine  life 
the  conchae  nasales  assume  approximately  their  definitive 
outlines,  and  the  corresponding  meatuses  become  well 
marked.  In  the  meatus  medius  two  accessory  folds  are 
distinctly  demonstrable, — the  previously  mentioned  proc- 
essus uncinatus  and  the  bulla  ethmoidalis, — which,  by  their 
variations  in  types  and  positions,  play  such  an  important 
part  in  determining  the  locations  of  the  ostia  of  the  cellulse 
ethmoidales  anterior.  In  the  meatus  superior  there  is 
often  found  an  accessory  fold  (Fig.  10),  which,  though  smaller, 
resembles  in  general  outline  the  bulla  ethmoidalis.  In  no 
instance  was  such  an  accessory  fold  found  in  any  of  the 
supreme  meatuses. 

The  cellulse  ethmoidales  develop  as  invaginations  of  the 
nasal  mucosa,  extending  into  the  lateral  masses  of  the 
ethmoid  from  the  primitive  grooves  or  furrows  in  the  lateral 
nasal  wall.  These  invaginations,  representing  the  primitive 
ethmoidal  cells,  appear  in  the  fourth  fetal  month  as  cylindric 
extensions  of  the  mucosa,  in  which  the  epithelial  surfaces 
are  in  contact.  As  the  diameters  of  the  invaginations  in- 
crease there  gradually  develop  lumina  within  the  cylindric 
processes  (Fig.  13),  which,  by  the  sixth  fetal  month,  usually 
show  distinct  cell  formation. 


46  THE    NASAL   ACCESSORY   SINUSES    IN   MAN 

CELLULE  ETHMOIDALES  ANTERIOR 

Primitive  cells  of  the  anterior  ethmoidal  group  develop 
earlier  and  more  rapidly  than  those  belonging  to  the  pos- 
terior group.  In  the  anterior  group  the  bullar  cells  are 
usually  the  first  to  be  distinctly  demonstrable.  It  was 
found  that  in  this  series  81.7  per  cent,  of  the  bullar  cells  had 
their  origin  from  the  suprabullar  furrow,  and  18.3  per  cent, 
from  the  infrabullar  furrow.  In  a  small  percentage  of  fetal 
as  well  as  postnatal  cases  a  shallow  groove  or  furrow  was 
found  on  the  infer omedial  surface  of  the  bullar  fold,  but  in 
no  such  case  was  the  invagination  sufficiently  deep  to  be 
indicative  of  actual  cell  formation. 

During  the  fourth  fetal  month  there  is  also  demonstrable 
an  expansion  of  the  meatus  medius  which  extends  in  an 
anterosuperior  direction,  forming  the  recessus  frontalis  of 
Killian.  We  believe  that  the  study  of  the  cellulae  eth- 
moidals anterior  and  the  relations  of  the  ostia  frontalia 
is  simplified  by  subdividing  this  recess  as  follows:  (a)  That 
portion  of  the  recess  lying  lateral  to  the  processus  uncina- 
tus  is  the  anterior  portion  of  the  infundibulum,  and  will  be 
termed  the  recessus  infundibularis.  From  this  recess 
smaller  invaginations  are  demonstrable  in  late  fetal  and  in 
early  childhood  specimens.  These  invaginations  are  the 
primitive  cellulae  infundibulares.  (b)  That  portion  of  the 
recessus  frontalis  lying  medial  to  the  processus  uncina- 
tus  forms  a  concavity  beneath  the  extreme  anterosuperior 
attachment  of  the  concha  media,  and  will  be  termed  the 
recessus  conchalis.  On  the  superior  portion  of  the  antero- 
lateral wall  of  the  recessus  conchalis  a  large  majority  of  late 
fetal  and  early  childhood  specimens  show  from  one  to  three 


THE    CELLULE    ETHMOIDALES 


47 


Fig.  13. — Diagram  Drawn  From  a  Horizontal  Section  Just  Above  the 

Anterior  Attachment  of  the  Concha  Superior.     (Series  A,  No.   13 

(one-hundred-and- twenty-six-day  fetus),  slide  10,  section  1.    X  3.) 

Specimen  shows  the  processes  of  pneumatization  developing  superiorly  into 

the  lateral   masses  of  the  ethmoid,  thus  forming  the  primitive  cellulae  eth- 

moidales.     Sept.na.,    Septum    nasi;     Infund.eth.,    infundibulum    ethmoidale; 

Cel.eth.ant.,  cellulse  ethmoidales  anterior;    Cel.eth.posf,.,   cellulae  ethmoidales 

posterior;   Epi.,  epithehal  invagination  from  meatus  superior. 


C.sup-^i f 


InlunAetJW 


Fig.  14. — Diagram  Drawn  From  a  Horizontal  Section  Just  Below  the 
Anterior  Attachment  of  the  Concha  Media  of  a  Fetus  One  Hundred 
AND  Twenty-six  Days  Old.     (Series  A,  No.  13,  shde  14,  section  1.    X  3.) 
Shows  well  the  relations  of  the  developing  infundibulum,  the  hiatus  semi- 
lunaris, and  the  bulla  ethmoidahs.     Ag.na.,  Agger  nasi;  Infund.eth.,  infundib- 
ulum   ethmoidale;    H.semi.,  hiatus    semilunaris;    B.eth.,    bulla    ethmoidalis; 
C.sup.,  concha  superior;  C.med.,  concha  media;  Proc.unc,  processus  uncinatus; 
Sept.na.,  septum  nasi. 


THE    CELLULE   ETHMOIDALES 


49 


Ag.aa. 

C.lTxf.       -^/^ 

Ves-t.Tv<a.-:— ^t 


Cap.T\as.posii. 
HypopK. 


Os-t.luh.aiud, 


Fig.  15. — Sagittal  Section  %  mm.  to  the  Right  of  Median  Line  An- 
teriorly AND  1  ^  MM.  TO  Right  of  Median  Line  Posteriorly  Through 
THE  Body  of  the  Sphenoid.  (Fetus  one  hundred  and  thirty-five  daj'^s  old. 
Series  B,  No.  L     X  1^.) 

Shows  the  lateral  nasal  wall  and  the  developing  sinus  sphenoidalis  which  ex- 
tends into  the  remnant  of  the  posterior  portion  of  the  cartilaginous  nasal 
capsule.  The  concha  sphenoidalis  (ossiculum  Bertini)  develops  in  that 
portion  of  the  cartilage  which  forms  the  antero-inferior  boundary  of  the  primi- 
tive sinus  sphenoidalis.  Cap.nas.post.,  Capsula  nasalis  posterior;  Hypoph., 
hypophysis;  Ost.tuh.aud.,  ostium  tubae  auditivse;  Vest.na.,  vestibulum  nasi; 
C.inf.,  concha  inferior;  Lob.,  lobulus;  Ag.na.,  agger  nasi;  C.med.,  concha 
media;  C.sup.,  concha  superior;  C.supr.L,  concha  suprema  I;  S.sph,  sinus 
sphenoidalis. 


THE    CELLULE   ETHMOIDALES 


51 


C.mediusccut  sxjrfe>.ce) 
C.sup. 
C.supr.l. 
c.supr.ll. 
.esuprm. 


Ag.  T\ 
B.a-tk 
Procuno. 

C.irvl 


S.spK. 
Ce.p.T\d.s.pos-t. 


^^\ Ost  .-tub.a-ud. 


Ton.. 


pa-1. 


Fig.  16. — Sagittal  Section,  Median  Anteriorly,  Posteriorly  1^  mm. 

TO  THE  Right  of  Median  Line.  (Fetus  one  hundred  and  eighty-eight  days 

old.     Series  B,  No.  4.) 

The  greater  portion  of  the  concha  media  has  been  removed  in  order  to  show 
the  relations  of  the  recessus  conchalis,  processus  uncinatus,  hiatus  semilunaris, 
and  bulla  ethmoidalis.  This  specimen  shows  the  presence  of  five  conchse 
ethmoidales,  the  only  specimen  in  the  entire  series  having  so  great  a  number. 
Note  the  extent  of  development  of  the  sinus  sphenoidalis.  C.med.,  Concha 
media  (cut  surface);  C.sup.,  concha  superior;  C.supr.l,  concha  suprema  I; 
C.supr.ll,  concha  suprema  II;  C.supr.ll  I,  concha  suprema  III;  S.sph., 
sinus  sphenoidalis;  Cap.nas.post.,  capsula  nasalis  posterior;  Ost.tuh.aud., 
ostium  tubae  auditivse;  Ton.pal.,  tonsilla  palatina;  C.inf.,  concha  inferior; 
Proc.unc,  processus  uncinatus;   B.eth.,  bulla  ethmoidalis;   Ag.na.,  agger  nasi. 


THE    CELLUL.E    ETHMOIDALES  53 

small  ridges  developing  from  the  posteromedial  surface  of 
the  processus  frontalis  of  the  maxilla.  These  small  ridges 
are  the  conchse  frontales,  and  from  the  furrows  or  depres- 
sions between  them,  or  between  them  and  the  surround- 
ing walls  of  the  recess,  the  cellulse  frontales  develop.  In 
Killian's  studies  of  a  large  number  of  specimens  from  late 
fetuses  and  infants  three  conchse  frontales  were  found  to 
represent  the  complete  number;  thus  four  cellulse  frontales 
may  develop.  This  type  of  development  is  shown  in  Fig.  36. 
However,  the  development  is  usually  not  so  complete  (Figs. 
20,  21,  38,  43,  51,  and  53).  Two  conchae  frontales  are 
usually  found  in  postnatal  specimens,  though  in  some  cases 
only  one,  and  in  still  others  none,  is  demonstrable. 

All  the  furrows  between  the  frontal  conchae  (whatever 
number  may  be  present)  do  not  necessarily  develop  into 
cells.  Specimens  from  older  children,  as  well  as  from  adults, 
show  that  some  form  distinct  cells,  some  persist  as  simple 
concavities  in  the  anterolateral  wall  of  the  recess,  and  others 
have  disappeared  or  else  were  never  present.  These  cells 
are  important  factors  in  the  development  of  the  sinus 
frontalis,  59.4  per  cent,  of  the  sinus  frontales  in  this  series 
having  had  their  origin  from  one  of  the  cells  lying  medial  to 
the  processus  uncinatus. 

The  manner  in  which  the  processus  uncinatus  is  attached 
to  the  agger  nasi,  its  relations  to  the  bulla  ethmoidalis,  and 
the  character  of  the  attachment  of  the  anterior  portion  of 
the  concha  media,  exert  the  greatest  influence  upon  the  pro- 
portion between  the  number  and  size  of  the  cellulae  frontales 
and  the  cellulse  infundibulares.  If  the  processus  uncinatus 
is  attached  to  the  posterolateral  portion  of  the  agger  nasi 
and  the  anterosuperior  attachment  of  the  concha  media  is 


54  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

high  up  on  the  lateral  nasal  wall,  then  the  cellulse  frontales 
are  apt  to  be  well  developed.  However,  if  the  anterior 
attachment  of  the  processus  uncinatus  is  more  medial  in 
position  and  the  anterosuperior  attachment  of  the  concha 
media  is  situated  lower  on  the  lateral  nasal  wall,  then  the 
recess  is  small,  the  cellulae  frontales  are  apt  to  be  deficient 
in  development,  and  there  is  usually  a  corresponding  in- 
crease in  both  the  number  and  the  extent  of  development  of 
the  cellulse  infundibulares. 

In  some  instances  the  infundibulum  ethmoidale  terminates 
anteriorly  as  an  expansion  into  a  single  cell.  However, 
there  are  usually  two  or  three  cellulse  infundibulares  present, 
and  in  some  instances  in  which  the  cellulae  frontales  were 
poorly  developed  four  were  found.  In  15.6  per  cent,  of 
cases  the  sinus  frontalis  developed  directly  from  the  in- 
fundibulum ethmoidale  (Fig.  35),  in  which  class  of  cases  there 
were  cells  anterior  and  lateral  to  the  ostium.  The  adult 
cellulse  infundibulares  are  usually  bordered  superiorly  by 
the  frontal  bone,  and  often  the  lateral  extent  is  such  that 
they  extend  well  into  the  supra-orbital  plate.  Not  infre- 
quently in  specimens  from  adults  and  also  from  older  chil- 
dren one  of  the  infundibular  cells  (Fig.  47)  forms  a  projection 
into  the  postero-inferior  portion  of  the  floor  of  the  sinus 
frontalis,  termed  by  Logan  Turner  the  bulla  frontalis. 
Observations  on  specimens  showing  the  conditions  present 
during  the  developmental  period  indicate  that  the  cell  de- 
veloped into  such  a  position  at  an  earlier  period  than  that 
at  which  the  sinus  frontalis  reached  so  far  in  its  lateral  de- 
velopment. Thus  the  developing  sinus  frontalis,  as  its 
pneumatization  extends  laterally,  passes  around  the  superior 
wall  of  the  cell  in  a  manner  which  makes  the  appearance. 


THE    CELLULiE   ETHMOIDALES 


55 


In.tur\cl.etVv. 
Cel.ei:K.a.rvt. 


Cel.etK.  posi:. 


^ — Uu  ct. TV  OL.  later. 


S.rn.e-«- 


Fig.  17. — Specimen  From  a  Child  Eight  Days  Old.  (Series  D,  No.  1.) 
By  sagittal  sections  removing  the  lateral  portion  of  frontal  bone,  lamina 
papyracea  of  ethmoid,  and  lateral  portion  of  maxilla — the  sinus  maxillaris, 
cellulse  ethmoidales,  anterior  and  posterior,  infundibulum  ethmoidale,  and  the 
primitive  sinus  frontalis  are  brought  into  view.  S.front.,  Primitive  sinus 
frontalis;  Duct.na.lacr.,  ductus  nasolacrimalis;  S.max.,  sinus  maxillaris; 
Cel.eth.post.,  cellulse  ethmoidales  posterior;  Cel.eth.ant.,  cellulse  ethmoidales 
anterior;   Infund.eth.,  infundibulum  ethmoidale. 


Hy  poph. 


Acj-nOb. 


Ost.tvjb.SLO. 


Ca.  lnc> 

Fig.  18. — Specimen  From  a  Child  Eight  Days  Old.  (Series  D,  No.  1.) 
Sagittal  section  in  median  line  through  frontal  and  maxillary  bones  and  3 
mm,  to  left  of  median  line  through  sphenoid  bone.  Shows  the  left  lateral 
nasal  wall,  the  ascending  and  the  descending  rami  of  the  meatuses,  also  the 
extent  of  development  of  the  sinus  sphenoidalis.  Note  that  the  antero-inferior 
wall  of  the  sinus  sphenoidaHs  (concha  sphenoidalis  or  ossiculum  Bertini)  is 
well  ossified.  Ag.na.,  Agger  nasi;  Ca.inc,  canalis  incisivus;  Rami  desc, 
rami  descendens  of  ethmoidal  meatuses;  Ost.tub.aud.,  ostium  tubae  auditivse; 
Hypoph.,  hypophysis;  S.sph.,  sinus  sphenoidalis;  Rami  asc,  rami  ascendens 
of  ethmoidal  meatuses. 


THE    CELLUL.E    ETHMOIDALES 


57 


C.rrted. 
N.i  n-f  re^orb, 


C.iTx-t. 


Fig.  19. — Specimen  From  a  Child  One  Month  and  Eight  Days  Old.     (Series 

D,  No.  2.) 
Posterior  view  of  coronal  section  cut  16  mm.  posterior  to  the  nasion,  showing 
the  extent  of  supero-inferior  and  lateral  development  of  sinus  maxillaris  and 
cellulse  ethmoidales  posterior.  Note  the  proximity  of  developing  teeth  to  the 
orbital  floor.  Cr.gal.,  Crista  galli;  Cel.eth.post.,  cellulse  ethmoidales  posterior; 
Proc.unc,  posterior  extremity  of  processus  uncinatus;  S.max.,  sinus  maxillaris; 
C.inf.,  concha  inferior;  N.infraorb.,  nervus  infraorbitalis;  C.med.,  concha 
media;  C.sup.,  concha  superior. 


B.etK. 
Os-t.b.etK. 
Cel.fe'tK.posir. 


S.irortt. 

ln.4un.cl.  e-t  K. 
■Duc-t.na^.la-CT. 


Ost.naaL-ic. 

S-YTVOl-X. 

Fig.  20. — Specimen  From  a  Child  Four  Months  and  Twenty-seven  Days 
Old.  (Series  D,  No.  5.) 
Lateral  portions  of  frontal,  ethmoidal,  and  maxillary  areas  have  been  re- 
moved to  show  the  extent  of  pneumatization.  S. front.,  sinus  frontahs  de- 
veloping from  a  furrow  in  the  recessus  conchaHs;  Infund.eth.,  infundibulum 
ethmoidale;  Duct.na.lacr.,  ductus  nasolacrimalis;  Ost.max.,  ostium  maxillare; 
S.max.,  sinus  maxillaris;  Cel.eth.post.,  cellula  ethmoidahs  posterior;  Ost.b.eth., 
ostium  bullae  ethmoidaUs,  opening  into  the  suprabullar  furrow;  B.eth.,  bulla 
ethmoidalis. 


THE    CELLULE    ETHMOIDALES 


59 


Cel.e-t  k.  p  OS t. 


da.  ng.  semi. 
CGasse^- 1") 


"For    op -tic 
A.Ca  r  .  I  n  t 

Moculorn.       J, 
N.troch ^ 


S.froo--t. 

Inturvd.e'tK. 
Fo3.  s&-o.la.c-i 


■¥- — Ost.Tne>.x. 


N.e>.bduo. 
A.Car.  irv-t. 

Fig.  21. — Specimen  From  a  Child  One  Year,  Four  Months,  and  Seven 
Days  Old.  Lateral  View  of  Frontal,  Ethmoidal,  and  Maxillary 
Sinus  Areas.     (Series  D,  No.  14.) 

S. front.,  Sinus  frontalis  developing  from  a  frontal  cell;  Infund.eth.,  infundib- 
ulum  ethmoidale;  Fos.sac.lacr.,  fossa  sacci  lacrimalis;  Ost.max.,  ostium 
maxillare;  N.abduc,  nervus  abducens;  A. car. int.,  arteria  carotis  interna; 
Gang.semi.,  ganglion  semilunare  (Gasseri);  N.troch.,  nervus  trochlearis; 
N.oculom.,  nervus  oculomotorius;  For. optic,  foramen  opticum;  Cel.eth.post., 
cellulse  ethmoidales  posterior;  Cel.eth.ant.,  cellulse  ethmoidales  anterior. 


THE    CELLULE   ETHMOIDALES 


61 


C .  s  u  p. 

C.  Supr.  H. 
C.sph.. 
S  spK. 


Hy  popK. 


Lob. 


C.ini 


Ton-.pVvoLV. 
Ost.  tub-aud. 


Fig.  22. — Specimen  From  a  Child  One  Year,  Ten  Months,  and  Thirteen 

Days  Old.     Sagittal  Section  Showing  Lateral  Wall  of  the  Nasal 

Cavity  and  the  Sinus  Sphenoidalis.     (Series  D,  No.  20.) 

Note  the  overlapping  of  the  concha  superior  by  the  anterior  portion  of  the 

concha  suprema  I ;  also  note  the  accessory  furrow  on  the  medial  surface  of  the 

concha  media.     In  a  plane  more  lateral  than  that  shown  in  the  illustration, 

the  sinus  sphenoidalis  is  more  extensively  developed  in  the  posterolateral 

direction,  its  inferolateral  wall  being  only  1  mm.  from  the  fossa  pterygopalatina 

and  2  mm.  from  the  foramen  rotundum,     C.med.,  Concha  media;    C.sup., 

concha  superior;   C.supr.  I,  concha  suprema  I;   C.swpr.  II,  concha  suprema  II; 

C.sph.,  concha  sphenoidalis    (ossiculum  Bertini);    S.sph.,  sinus  sphenoidalis; 

Hypoph.,  hypophysis;    Ton.phar.,  tonsilla  pharyngea;    Ost.tub.aud.,  ostium 

pharyngeum  tubse  auditivae;  C.inf.,  concha  inferior;  Lob.,  lobulus. 


THE    CELLULE   ETHMOID  ALES  63 

as  found  in  some  adult  specimens,  such  that  the  cell  might 
readily  be  regarded  as  having  caused  the  projection  into  the 
floor  of  a  previously  developed  sinus.  Cells  of  this  group 
may  also  extend  far  anteriorly — sometimes  even  anterior 
to  the  anterior  wall  of  the  ductus  nasolacrimalis  (Fig.  47). 

A  majority  (65  per  cent.)  of  specimens  from  cases  over  two 
years  of  age  show  a  cell  or  a  part  of  a  cell  which  has  developed 
so  as  to  produce  pneumatization  of  the  prominence  termed 
the  agger  nasi  or  nasoturbinal.  The  agger  nasi  appears  in 
the  latter  part  of  the  second  or  the  first  part  of  the  third 
fetal  month  as  a  prominence  on  the  anterior  portion  of  the 
lateral  nasal  wall,  extending  antero-inferiorly  from  the 
anterior  attachment  of  the  concha  media,  approximately 
parallel  to  the  nasal  bones.  As  a  rule,  the  agger  nasi  is 
relatively  more  prominent  in  late  fetuses  and  infants  than 
it  is  in  older  individuals.  Of  the  65  per  cent,  of  cases  over 
two  years  old  showing  pneumatization  of  the  agger  nasi,  it 
was  found  that  in  60  per  cent,  of  such  cases  the  pneumatiza- 
tion had  extended  from  the  anterior  cellula  frontalis  (Figs. 
36  and  51),  and  in  40  per  cent,  from  the  anteromedial  cellula 
infundibularis  (Fig.  27).  The  location  of  these  cells  is  such 
as  to  require  careful  inspection  by  operating  surgeons,  lest 
their  presence  be  overlooked  when  wishing  to  eradicate  frontal 
and  infundibular  cells. 

The  bulla  ethmoidalis  may  contain  either  a  single  large 
cell  or  else  from  two  to  four  smaller  ones.  One  buUar  cell 
was  present  in  25  per  cent,  of  specimens,  two  cells  in  62  per 
centi^  three  cells  in  10  per  cent.,  and  four  cells  in  3  per  cent, 
of  202  postnatal  lateral  nasal  walls.  Of  these  cells,  81.7  per 
cent,  had  their  origin  from  the  suprabullar  furrow,  and  18.3 
per  cent,  from  the  infrabullar  furrow.     Whatever  the  num- 


64  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

ber  of  cells  may  be,  or  from  whatever  point  they  may  have 
had  their  origin,  pneumatization  extends  from  the  medial 
wall  of  the  bulla  to  the  lamina  papyracea;  and  in  many 
instances  for  a  variable  distance  into  the  supra-orbital  plate 
of  the  frontal  bone.  Occasionally  there  is  a  less  marked 
extent  into  the  infra-orbital  plate  of  the  maxilla. 

The  inferomedial  wall  of  the  bulla  is  usually  a  well- 
rounded  one  (Figs.  9,  27,  and  36),  but  in  some  cases  (Figs. 
16,  51,  and  53)  it  forms  a  narrower  projection.  The  varia- 
tions in  the  size  and  form  of  the  bulla  not  only  influence 
the  bullar  cells,  but  also,  in  conjunction  with  the  variations 
in  the  processus  uncinatus,  determine  the  width  and  length 
of  the  hiatus  semilunaris, — the  interval  between  the  antero- 
inferior surface  of  the  bulla  and  the  posterosuperior  surface 
of  the  processus  uncinatus, — which  is  the  opening  by  means 
of  which  the  meatus  medius  communicates  with  the  infun- 
dibulum  ethmoidale.  The  length  of  the  hiatus  semilunaris 
varies  in  adult  types  from  14  to  27  mm.,  this  wide  variation 
being  due  to  the  manner  in  which  the  anterosuperior  end 
of  the  processus  uncinatus  is  attached  to  the  bullar  fold. 
Cases  in  which  the  hiatus  is  short  show  at  its  anterior 
border  a  wide  plate,  passing  between  the  bulla  and  the  proc- 
essus uncinatus  (Figs.  36,  51,  and  56). 

The  width  of  this  plate  varies  from  11  mm.  to  complete 
absence.  In  cases  in  which  the  plate  is  absent  (Figs.  27 
and  38)  the  hiatus  extends  upward  to  the  level  of  the  cribri- 
form plate,  thus  allowing  a  closer  communication  between 
the  recessus  infundibularis  and  the  recessus  conchalis  than 
is  usually  found. 


THE    CELLULiE    ETHMOIDALES 


65 


Cel.  iaturxd 

Cel.tron.t. 

lafun.ci.etK. 


S.fToa-t. 

Ost.fror\t. 
rocurv-c. 
C.iTxed. 
Sept.rva^. 
S.rt\a.x- 


N.xriiroLor\3. 


Fig.  23. — Specimen  From  a  Child  Two  Years,  Six  Months,  and  Seven 
Days  Old.  (Series  D,  No.  24.) 
Posterior  view  of  a  coronal  section  11  mm.  posterior  to  nasion.  Note  that 
the  ostia  of  the  frontal  sinuses  are  medial  to  the  uncinate  processes,  thus  do 
not  communicate  with  the  infundibulum  ethmoidale.  S. front.,  Sinus  frontalis; 
Ost.front.,  ostium  frontale;  Proc.unc,  processus  uncinatus;  C.med.,  concha 
media;  Sept.na.,  septum  nasi;  S.max.,  sinus  maxillaris;  N.infraorb.,  nervus 
infraorbitalis;  C.inf.,  concha  inferior;  Infund.eth.,  infundibulum  ethmoidale; 
Cel.front.,  cellula  frontalis;  Cr.gal.,  crista  galli. 


THE    CELLULE   ETHMOIDALES 


67 


S. front 


C  e  l-lrvi  und 
laiurvcLe-tK. 


S.ITV.  d-  -x. 


For.  e t K.poa-t 

For.  opti.  c> 
A  .ca.r.  irv.t. 


S.ca-v. 


*"  For.rotvjnc'iunrv 

Fig.  24. — Specimen  From  a  Child  Two  Years,  Six  Months,  and  Twelve 
Days  Old.  (Series  D,  No.  25.) 
Lateral  view  of  left  frontal,  ethmoidal,  and  maxillary  sinus  areas.  Note 
advance  of  sinus  frontalis  into  the  vertical  portion  of  the  frontal  bone.  Cel. 
b.eth.,  Cellulae  bullae  ethmoidales;  Cel.eth.post.,  cellula  ethmoidalis  posterior; 
For.eth.post.,  foramen  ethmoidale  posterius;  For. optic,  foramen  opticum; 
A.car.int.,  arteria  carotis  interna;  S.cav.,  sinus  cavernosus;  S.sphenopar., 
sinus  sphenoparietalis;  For.rotundum.,  foramen  rotundum;  S.max.,  sinus 
maxillaris;  Infund.eth.,  infundibulum  ethmoidale;  Cel.infund.,  cellulse  in- 
fundibulares;  S.front.,  sinus  frontalis. 


THE    CELLULE    ETHMOI DALES 


69 


Co.r  t.sep.  r\ 
Proc.  urva 


M.ia-fraorb. 


Fig.  25. — Specimen  From  a  Child,  Three  Years  Five  Months,  and  Eight 
Days  Old.  (Series  D,  No.  32.) 
Posterior  view  of  coronal  section  cut  2S.5  mm.  posterior  to  nasion,  showing 
the  extent  of  lateral  and  supero-inferior  development  of  sinus  maxillaris,  the 
osseous  ridge  beneath  nervus  infraorbitalis,  cellulse  ethmoidales  posterior, 
and  small  conchal  cells  developing  in  each  concha  nasalis  superior.  The  ostia 
maxillaria  are  larger  than  usual  in  the  anteroposterior  diameter.  Note  de- 
flection of  septum  nasi  and  its  influence  on  each  concha  media.  C.sup., 
Concha  superior;  Cel.eth.post.,  cellulse  ethmoidales  posterior;  C.med.,  concha 
media;  N.infraorh.,  nervus  infraorbitalis;  C.inf.,  concha  inferior;  Proc.unc, 
processus  uncinatus;  Cart.sep.na.,  cartilago  septi  nasi;  Lam. perpend.,  lamina 
perpendicularis. 


THE   CELLULE  ETHMOIDALES 


71 


.Cel.iroTv-t. 


P  roo 


Fig.  26. — Specimen  From  a  Child  Four  Years,  Seven  Months,  and  Nine- 
teen Days  Old.  (Series  D,  No.  40.) 
Anterior  view  of  coronal  section,  cut  16  mm.  posterior  to  the  nasion,  show- 
ing the  lateral  and  supero-inferior  extent  of  the  maxillary  sinuses,  their  rela- 
tions to  developing  teeth,  and  the  relations  of  the  ostium  maxillare  to  the 
infundibulum  ethmoidale.  Note  ridge  beneath  the  right  nervus  infraorbit- 
alis.  The  bullar  cells  have  their  ostia  in  the  suprabullar  furrow.  The  ostia 
of  the  cellulae  frontales  are  medial  to  the  processus  uncinatus  and  the  bulla 
ethmoidalis.  Cel.front.,  Cellulae  frontales;  Cel.b.eth.,  cellulae  bullae  ethmoid- 
ales;  Infund.eth.,  infundibulum  ethmoidale;  Ost.max.;  ostium  maxillare; 
N.infraorb.,  nervus  infraorbitahs;  S.max.,  sinus  maxillaris;  Proc.unc,  pro- 
cessus uncinatus. 


THE    CELLULiE   ETHMOIDALES 


73 


H.  semi . 

Cel  .etK.post. 

C  rrted.  (cu-t  surfa.c-&) 
C.  sup. 

C.  Supr.I. 
S.  sph-. 

Hy popK, 


CeLlrxfund 
B.  ctK 


roc.  vjn  c. 


Seplr.spK. 


J — Torv.  pKi 


Os-t.tub.a-od, 


C.in.1 


Os-t.m.etx 


Fig.  27. — Specimen  From  a  Child  Five  Years,  Ten  Months,  and  Twenty- 
two  Days  Old.  (Series  D,  No.  45.) 
Sagittal  section,  %  mm.  to  the  right  of  median  hne  anteriorly;  section 
through  body  of  the  sphenoid  2  mm.  to  the  right  of  median  line.  Anterior 
portion  of  concha  media  has  been  removed  to  show  the  lateral  nasal  wall. 
Medial  wall  of  an  infundibular  cell  was  removed  with  the  anterior  attachment 
of  the  concha  media.  Ostium  frontale  in  this  case  communicates  both  with 
infundibulum  and  with  the  recessus  conchaHs  medial  to  the  processus  un- 
cinatus.  Dotted  line  indicates  outline  of  sinus  frontalis.  H.semi.,  Hiatus 
semilunaris;  Cel.eth.post.,  cellula  ethmoidalis  posterior,  extending  into  concha 
media;  Cmed.,  concha  media  (cut  surface) ;  C.swp.,  concha  superior;  C.supr.I, 
concha  suprema  I ;  >S.sp/i.,  sinus  sphenoidalis;  Hypoph.,  hypophysis;  Sept.sph., 
septum  sphenoidale  (anterior  portion);  Ton.phar.,  tonsilla  pharyngea;  Ost. 
tub.aud.,  ostium  pharyngeum  tuba?  auditivse;  Ost.max.acces.,  ostium  maxillare 
accessorium;  C.inf.,  concha  inferior;  Proc.unc,  processus  uncinatus;  B.eth., 
bulla  ethmoidahs;   Ag.na.,  agger  nasi;   Cel.infund.,  cellula  infundibularis. 


THE    CELLULE   ETHMOIDALES 


76 


1  tvi  u  ad .  e  -k  K 


S.nrvcv 


'■^1SJ>1 


Cel  e-tH.An.-t. 

Ccl.e-tJrv.po*-' 


Tor  roturvciurn. 
Fos.ptery  gopa.'V. 

Fig.  28. — Specimen  From  a  Child  Five  Years,  Ten  Months,  and 
Twenty-two  Days  Old.  Lateral  View  of  Frontal,  Ethmoidal, 
Sphenoidal,  and  Maxillary  Areas  to  Show  the  Extent  of  Pneu- 
matization  Present  and  the  Relations  of  the  Sinuses.  (Series  D, 
No.  45.) 

Osseous  wall,  between  sinus  sphenoidalis  and  fossa  pterygopalatina,  is  ^ 
mm.  thick,  while  from  sinus  cavity  to  foramen  rotundum  is  1  mm.  Sinus 
frontalis  developed  from  an  infundibular  cell.  Cel.eth.ant.,  Cellulae  ethmoidales 
anterior;  Cel.eth.post.,  cellulae  ethmoidales  posterior;  S.sph.,  sinus  sphenoidalis; 
For.optic,  foramen  opticum;  A.car.int.,  arteria  carotis  interna;  N.abduc, 
nervus  abducens;  For. rotundum,  foramen  rotundum;  Fos.pterygopal.,  fossa 
pterygopalatina;  S.max.,  sinus  maxillaris;  Infund.eth.,  infundibulum  eth- 
moidale;  S. front.,  sinus  frontalis. 


THE    CELLULE   ETHMOIDALES  77 

CELLULE  ETHMOIDALES  POSTERIOR 
The  cellulse  ethmoidales  posterior  vary  in  number  from 
one  to  five  on  each  side,  the  general  average  in  202  lateral 
nasal  walls  being  2.62.     The  origin  of  the  posterior  cells  was 
found  to  be  as  follows: 

81.1  per  cent,  from  the  meatus  superior 
18.4     ''       ''       ''         ''  "     supremusi 

0.5     ''      ''      ''        ''  "  "        II 

The  ostia  of  the  cells  vary  from  oval  openings  0.5  mm.  to 
3  mm.  in  diameter,  to  slit-like  openings  from  3  to  14  mm. 
long  and  from  1  to  3  mm.  wide.  The  most  constant  loca- 
tion for  an  ostium  is  at  the  anterolateral  extremity  of  the 
meatus  superior.  In  only  one  instance  was  a  superior  meatus 
found  which  contained  no  ostium  for  an  ethmoidal  cell.  In 
that  case  posterior  ethmoidal  pneumatization  was  entirely 
from  the  meatus  supremus  I. 

The  extent  of  pneumatization  shows  marked  variations. 
Posterior  cells  often  extend  for  variable  distances  into  the 
supra-orbital  plate  of  the  frontal  bone,  into  the  orbital  proc- 
ess of  the  palate  bone,  into  the  infra-orbital  plate  of  the 
maxilla,  and  in  rare  instances  may  invade  the  body  of  the 
maxilla,  forming,  when  the  pneumatization  is  extensive, 
what  has  been  termed  a  double  maxillary  sinus.  Fig.  50 
shows  an  aberrant  cell  which  had  its  origin  in  the  superior 
meatus,  invading  the  posterosuperior  portion  of  the  maxilla, 
but  the  invasion  in  this  case  is  not  sufficient  to  justify  its 
classification  as  a  double  maxillary  sinus. 

The  most  posterior  ethmoidal  cell  frequently  develops 
dorsally  until  a  portion  of  it  lies  superior  to  the  ventral  por- 
tion of  the  sinus  sphenoidalis,  but  in  no  case  was  there  a 


78  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

communication  found  between  a  posterior  ethmoidal  cell 
and  the  sphenoidal  sinus. 

CELLULJE  CONCHALES 

Pneumatization  of  the  conchse  ethmoidales  is  a  rather 
common  condition,  occurring  in  from  4  per  cent,  to  18  per 
cent,  of  cases  studied  by  various  observers.  In  this  series 
such  cells  were  found  in  8  per  cent,  of  cases  over  ten  years  of 
age,  and  in  3  per  cent,  under  that  age.  Observations  as  to 
their  possible  points  of  origin  are  in  accord  with  the  studies 
made  by  J.  P.  Schaeffer.  In  the  majority  of  instances  such 
cells  developed  as  extensions  of  posterior  ethmoidal  cells 
communicating  with  the  superior  meatus,  but  other  cases 
showed  origins  from  the  posterior  extremity  of  the  infundib- 
ulum  ethmoidale,  and  still  others  from  the  suprabuUar  furrow 
(Fig.  46). 

The  mucosa  lining  these  cells  was  similar  to  that  lining 
other  ethmoidal  cells.  In  none  of  these  cases  did  the  cells 
contain  fluids  or  granulation  tissue.  However,  one  can 
readily  see  how  some  of  the  earlier  observers,  who  found  such 
turbinates  in  diseased  condition,  came  to  regard  the  conchal 
cells  as  cysts. 

In  many  instances  the  stimulus  exciting  the  development 
of  these  cells  seems  to  have  been  produced  by  a  deflection 
of  the  septum  nasi, — the  concha  media  on  the  side  of  the 
concavity  showing  the  presence  of  an  air-cell  in  its  anterior 
portion, — thus  aiding  in  its  compensatory  hypertrophy. 
Fig.  46  illustrates  such  a  case,  but  the  stimulus  in  all  cases 
cannot  be  attributed  to  such  a  cause,  since  occasionally 
specimens  have  been  observed  in  which  both  middle  conchse 
contained  such  cells. 


THE  SINUS  MAXILLARIS 

The  sinus  maxillaris  is  the  most  constant  of  the  nasal 
accessory  sinuses.  Reschreiter  mentions  reports  of  four 
cases  in  which  a  sinus  maxillaris  was  absent.  We  have 
found  no  other  instances  in  which  complete  failure  of  its 
development  has  been  recorded.  The  extent  of  its  develop- 
ment is  also  more  regular  than  that  of  any  of  the  other 
sinuses,  as  was  shown  by  comparing  the  tables  of  measure- 
ments given  by  the  various  observers. 

In  embryos  eighty-five  days  old  there  is  a  lateral  out- 
pouching of  mucosa,  demonstrable  in  the  inferolateral  por- 
tion of  the  wall  of  the  infundibulum  ethmoidale,  slightly 
anterior  to  its  midpoint  anteroposteriorly.  This  is  the 
primitive  sinus  maxillaris,  which  gradually  develops  as  an 
oblong  recess,  extending  first  into  the  lateral  nasal  capsule, 
after  the  resorption  of  which  it  continues  its  advance  and 
development  into  the  maxilla.  The  point  of  primary  lat- 
eral pouching  persists  as  the  ostium  maxillare. 

As  the  expansion  in  the  maxilla  increases  anteroposteriorly 
much  more  rapidly  than  does  the  diameter  of  the  ostium, 
there  is  thus  developed  a  medial  wall,  which,  by  the  latter 
part  of  the  sixth  or  early  in  the  seventh  fetal  month,  is 
sufficient  to  make  the  outline  of  the  pouching  demonstrable 
as  an  oblong  sinus.  The  relatively  small  vertical  diameters 
of  fetal  and  infantile  maxillae  and  the  close  approximation 
of  the  developing  teeth  to  the  orbital  floor  preclude  the 
possibility  of  a  rapid  increase  in  the  vertical  and  lateral 

79 


80  THE   NASAL  ACCESSORY   SINUSES   IN   MAN 

diameters  of  the  sinus  during  these  early  periods.  In  the 
case  of  a  child  eight  days  old  the  sinus  diameters  were  found 
to  be  8.2  mm.  anteroposteriorly,  3.3  mm.  vertically,  and  2.8 
mm.  laterally  (Fig.  17  was  drawn  from  this  specimen). 
As  the  body  of  the  maxilla  increases  in  size  there  is  a  cor- 
responding increase  in  the  extent  of  pneumatization.  Up 
until  the  eighth  year  the  diameters  of  the  sinus  maxillaris 
increase  at  a  rate  which  was  found  to  average  approximately 
2  mm.  each  year  in  both  the  vertical  and  the  lateral  di- 
ameters, and  3  mm.  anteroposteriorly.  After  the  eighth 
year  the  development  of  the  sinus  advances  more  slowly  in 
all  directions,  reaching  in  the  fifteenth  to  the  eighteenth 
year  a  form  which  approximates  the  adult  type,  later  changes 
being  shown  chiefly  in  the  postero-inferior  angle,  which  de- 
scends as  the  third  molar  tooth  erupts. 

The  following  table  shows  the  average  diameters  of  the 
ostia  maxillaria  and  of  the  sinus  maxillares,  as  found  in  the 
various  ages.  All  measurements  are  given  in  millimeters. 
(In  considering  the  relation  of  the  sinus  floor  to  the  nasal 
floor,  measurements  preceded  by  a  plus  sign  indicate  that 
the  average  sinus  floor  was  found  to  be  the  given  distance 
above  the  level  of  the  nasal  floor.  Measurements  preceded 
by  a  minus  sign  indicate  that  the  average  sinus  floor  was  the 
given  distance  below  the  level  of  the  nasal  floor.) 

From  this  table  it  is  seen  that  the  floor  of  the  sinus 
maxillaris,  in  an  average  case,  reaches  a  level  equal  to  that 
of  the  floor  of  the  nasal  fossa  during  the  eighth  year,  and 
in  the  majority  of  older  cases  is  from  1  mm.  to  5.5  mm.  below 
the  level  of  the  nasal  floor,  regardless  of  the  sex  of  the  indi- 
vidual. Reschreiter  regarded  a  floor  of  the  sinus  maxiflaris 
below  the  level  of  the  nasal  floor  as  a  male  characteristic. 


THE    SINUS   MAXILLARIS 


81 


TABLE  OF  AVERAGES  OF  THE  SINUS  MAXILLARIS 


Age 


8  days-1  yr 

1-2  yrs.  .  . 

2-3  yrs.  .  . 

3-4  yrs.  .  . 

4-5  yrs.  .  . 

5-6  yrs.  .  . 

6-7  yrs.  .  . 

7-8  yrs.  .  . 

8-9  yrs.  .  . 

9-10  yrs.  . 
10-11  yrs.  . 
11-12  yrs.  . 
12-13  yrs.  . 
13-14  yrs.  . 
14-15  yrs.  . 
15-16  yrs.  . 
16-17  yrs.  . 
17-18  yrs.  . 
18-19  yrs.  . 
19-20  yrs.  . 
20-21  yrs.  . 
21-22  yrs.  . 
22-23  yrs.  . 
23-24  yrs.  . 
25  yrs.  .  .  . 


NUM- 
BKR  OF 

Cases 


10 
10 
8 
6 
8 
3 
8 
5 
5 
2 
2 
1 
1 
3 
1 
3 
4 
4 
1 
3 
2 
1 
2 
1 
2 


Side 


Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 

Left 

Right 


Diameters 

OF  OSTIA 


1.5x0.6 
1.5x0.6 
2.1x0.8 
2.0x0.7 
2.0x0.8 
2.4x0.8 
3.9x0.8 
4.1x0.8 
2.7x1.0 
3.4x1.1 
3.3x1.1 
3.4x1.0 
3.6x1.1 
4.0x1.3 
3.9x1.0 
3.7x1.0 
3.7x1.4 
3.2x1.1 
4.0x2.5 
2.8x1.0 
4.5x1.3 
5.0x1.3 
3.0x1.0 
3.0x1.0 
3.5x1.5 
2.5x0.8 
3.7x1.1 
3.4x0.8 
3.0x1.0 
2.5x1.0 
3.7x1.3 
3.3x1.8 
4.7x2.0 
5.0x3.0 
3.3x1.5 
3.4x1.6 
3.5x1.0 
3.0x1.0 
4.1x1.3 
4.5x1.4 
3.5x1.0 
3.5x1.0 
4.5x2.0 
5.0x1.5 
3.5x1.7 
4.0  X  2.2 
2.5x1.3 
3.0x1.2 
7.0x1.5 
7.5x1.6 


Diameters  of 

Sinus 

Antero- 

Vertical 

Lateral 

poste- 
rior 

5.7 

4.6 

13.3 

5.4 

4.7 

13.4 

8.3 

6.7 

17.9 

8.0 

6.6 

17.9 

9.2 

7.9 

20.2   ' 

9.3 

8.0 

20.3   j 

11.1 

9.1 

21.9 

11.3 

9.5 

22.3   I 

12.3 

13.1 

25.0   1 

12.8 

13.3 

25.6 

12.3 

14.0 

26.2 

12.7 

13.2 

27.0 

17.7 

16.8 

28.5 

17.2 

16.6 

28.3 

19.1 

15.2 

27.2 

19.1 

14.7 

26.7 

21.4 

17.9 

29.5 

21.9 

17.8 

30.2 

18.5 

19.0 

30.5 

18.5 

16.5 

29.5 

21.0 

18.0 

27.5 

21.5 

17.5 

27.7 

22.0 

18.5 

29.0 

22.5 

19.0 

29.0 

19.0 

15.0 

25.0 

17.5 

15.0 

25.0 

23.6 

18.0 

31.1 

23.8 

17.6 

30.3 

25.0 

18.0 

28.0 

25.0 

17.5 

29.0 

33.0 

26.2 

39.2 

32.2 

26.5 

39.0 

24.7 

20.8 

35.0   1 

25.8 

21.1 

33.8 

32.2 

24.5 

36.0 

32.0 

24.6 

36.2 

29.0 

25.5 

28.0 

30.0 

21.0 

25.0 

32.3 

21.3 

32.3 

32.1 

21.6 

33.6 

26.5 

20.0 

32.0 

26.5 

20.0 

32.5 

27.0 

18.0 

34.0 

23.0 

17.5 

26.5 

29.5 

24.5 

34.5 

29.2 

23.8 

35.0 

27.0 

15.0 

24.0 

29.0 

17.5 

31.0 

27.8 

20.5 

32.5 

29.0 

21.5 

32.8 

Relation 

TO  Nasal 
Floor 


+4.3 

+4.0 
+3.7 
+3.7 
+3.6 
+3.6 
+2.6 
+2.4 
+2.7 
+2.1 
+2.5 
+2.0 
+0.6 
+0.9 
-0.2 
-0.1 
-0.6 
-1.4 
+  1.0 
+0.5 
+  1.0 
+0.2 
-2.0 
-2.0 
+  1.0 
+2.0 
-1.0 
-0.8 
-2.0 
-2.0 
-7.5 
-7.0 
-0.3 
-1.5 
-5.5 
-5.2 
-0.2 
-  1.0 
-2.5 
-3.6 
-1.7 
-1.7 
-3.5 
+  1.5 
-3.5 
-2.8 
-2.0 
-4.0 
-4.2 
-5.5 


6 


82  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

However,  in  this  series  there  was  found  no  definite  rela- 
tionship between  the  sex  of  the  individual  and  the  level  of 
the  floor  of  the  sinus  maxillaris.  . 

In  early  childhood  the  general  outline  of  the  sinus  is 
rather  ovoid  (Figs.  20,  21,  24,  and  25),  but  in  later  childhood 
it  is  gradually  changed  into  a  pyramidal  form  (Figs.  28, 
30,  33,  37,  and  52),  which  persists  as  the  usual  adult  type. 
The  base  is  directed  toward  the  nasal  fossa,  and  corresponds 
to  the  medial  wall,  while  the  apex  extends  into  the  processus 
zygomaticus. 

The  form  of  the  sinus  maxillaris  is  usually  described,  as  a 
three-sided  pyramid  with  irregularly  rounded  corners.  In 
such  descriptions  the  portion  overlying  the  alveolar  process 
is  separately  classed  as  the  floor,  without  giving  it  a  part 
in  the  formation  of  the  triangular  pyramid.  We  believe  it 
more  consistent  to  consider  the  form  as  quadrilateral  at  its 
base,  but  becoming  triangular  as  the  apex  is  approached. 
The  anterior  and  the  posterior  walls,  being  more  closely 
approximated  inferiorly  than  superiorly,  as  the  apex  of  the 
pyramid  is  approached,  the  rounded  inferior  angles  are 
brought  so  close  together  that  the  resulting  single  rounded 
angle  becomes  the  inferior  boundary  in  the  apical  portion. 
Examples  of  the  usual  quadrilateral  type  of  the  base  are 
seen  in  Figs.  30,  33,  45,  and  49.  A  much  less  frequent  type 
is  shown  in  Figs.  50  and  55,  in  which  variety  there  is  a  some- 
what triangular  basal  outline.  This  type  is  found  only  in 
association  with  a  very  deep  fossa  canina. 

In  its  lateral  development  the  average  sinus  maxillaris, 
at  the  end  of  the  first  year,  has  come  into  close  relation  with 
the  nervus  infraorbi talis.  During  the  second  year  the  most 
lateral  portion  of  the  sinus  passes  beneath  the  nerve,  leaving 


THE    SINUS   MAXILLARIS 


83 


ji.  i? 


C.  med 


Cvai 


Fig.  29. — Specimen  From  a  Child  Six  Years  Old.  Sagittal  Section 
Showing  Extent  of  Sphenoidal  Pneumatization.  (Series  D,  No.  46.) 
The  child  from  whom  this  specimen  was  taken  died  of  nasal  diphtheria. 
Note  areas  of  submucous  hemorrhages.  The  nasal  cavities  were  completely 
filled  with  pseudomembrane,  as  were  also  the  frontal  sinuses  and  ethmoidal 
cells,  while  the  maxillary  and  sphenoidal  sinuses  were  approximately  half 
filled.  Also  note  the  enormous  tonsilla  pharyngea,  which  nearly  fills  the  pos- 
terior naris.  C.sup.,  Concha  superior;  C.swpr.I,  concha  suprema  I;  S.sph., 
sinus  sphenoidalis;  Hypoph.,  hypophysis;  Ton.phar.,  tonsilla  pharyngea; 
F.phar.bas.,  fascia  pharyngobasilaris;  C.inf.,  concha  inferior;  C.med.,  concha 
media. 


THE    SINUS   MAXILLARIS 


85 


Cel.b.etK 


N. op  tie 
N.opKtVvA.1 

N-ooulo  m. 

N.trocKI        __ 


Cel.tn.-iu  ad. 


Ga-rtg.s  enai 


A.  ear  Aa-t         7g 


l^os.  sa>.c.la.cr. 


Os-t.m.a.x. 


Os-t.  rrxa^x .  cxcce 


n-LUcous   cysts 


Fig.  30. — Specimen  From  a  Child  Six  Years,  Ten  Months,  and  Twenty 
Days  Old.  By  Sagittal  Sections  the  Lateral  Portions  of  the 
Frontal,  Ethmoidal,  and  Maxillary  Areas  Have  Been  Removed. 
(Series  D,  No.  53.) 

The  osseous  ridges  on  the  medial  wall  of  the  sinus  maxillaris  are  unusually 
prominent.  The  largest  one  overlies  the  ductus  nasolacrimalis.  There  were 
two  lacrimal  sacs  present,  the  superior  portion  of  the  duct  being  bifid.  Note 
presence  of  ostium  maxillare  accessorium  and  the  proximity  of  the  mucous 
cyst.  S. front.,  Sinus  frontalis;  Cel.infund.,  cellulae  infundibulares;  Fos.sac. 
lacr.,  fossae  sacci  lacrimales;  Ost.max.,  ostium  maxillare;  Ost.max.acces., 
ostium  maxillare  accessorium;  N .max.,  nervus  maxillaris;  N.mandih.,  nervus 
mandibularis;  Gang.semi.,  ganglion  semilunare  (Gasseri);  N.abduc,  nervus 
abducens;  A.car.int.,  arteria  carotis  interna;  N.troch.,  nervus  trochlearis; 
N.oculom.,  nervus  oculomotorius;  N.ophthal.,  nervus  ophthalmicus;  N .optic, 
nervus  opticus;  Cel.eth.post.,  cellulae  ethmoidales  posterior;  Cel.b.eth.,  cellula 
bullae  ethmoidalis. 


THE    SINUS   MAXILLARIS 


87 


Os.aasd.le       ^ 


ypoph.. 


rt.s  e  p  rv  a. 


Ton..pKa.i 
Os-t.-tuh 


Fig.  31. — Specimen  From  a  Child  Six  Years,  Ten  Months,  and  Twenty 
Days  Old.  Lateral  View  of  This  Specimen  is  Shown  in  Fig.  30. 
(Series  D,  No.  53.) 

Sagittal  section  Yi  mm.  to  the  left  of  median  line,  showing  extent  of  sinus 
sphenoidalis  and  also  the  relation  of  the  structures  entering  into  the  formation 
of  the  septum  nasi.  Cr.gal.,  Crista  galli;  Lam.perpend.,  lamina  perpen- 
dicularis;  S.sph.,  sinus  sphenoidalis;  Hypoph.,  hypophysis;  Ton.phar., 
tonsilla  pharyngea;  Ost.tub.aud.,  ostium  pharyngeum  tubse  auditivse;  Cart, 
sept.na.,  cartilago  septi  nasi. 


THE    SINUS   M AXILLARIS 


89 


N-optic. 


Cm.  e 


e.i-n.-}. 


iM.o.pteryg. 
(Vidit) 


Fig.  32. — Specimen  From  a  Child  Seven  Years,  Nine  Months,  and  Twelve 
Days  Old.  (Series  D,  No.  58.) 
Coronal  section  through  the  anterior  portion  of  the  body  of  the  sphenoid 
bone,  to  show  the  relations  of  the  cranial  nerves  to  the  sphenoidal  area.  The 
sphenoidal  sinuses  in  this  specimen  show  less  extensive  pneumatization  of  the 
body  of  the  sphenoid  than  is  usually  seen  at  this  age.  N.optic,  Nervus  opti- 
cus; N.troch.,  nervus  trochlearis;  N.oculom.,  nervus  oculomotorius;  N.abduc, 
nervus  abducens;  N.ophthal.,  nervus  ophthalmicus;  N.max.,  nervus  maxil- 
laris;  Nx.pteryg.,  nervus  canalis  pterygoidei  (Vidii);  Ton.phar.,  tonsilla 
pharyngea;  C.inf.,  concha  inferior;  C.med.,  concha  media;  S.sph.,  sinus 
sphenoidaUs;  S.cav.,  sinus  cavernosus. 


THE    SINUS   MAXILLARIS 


91 


Ce\  etK.po^t. 


S.  front 


Fos  so.c,ls.cr 


Ost  mo^x 


Mucous     — 
cysts      ^ 


Fos.  ptery  cjopecL 


Ost  .rnax  .eccc.es. 


Fig.  33. — Specimen  Frcxm  a  Child  Eight  Years,  Two  Months,  and  Ten 
Days  Old.  (Series  D,  No.  59.) 
Lateral  view  of  frontal,  ethmoidal,  and  maxillary  areas.  Note  that  the 
sinus  frontalis  developed  from  a  cell  having  its  origin  from  the  suprabullar 
furrow.  The  right  sinus  frontalis  had  a  similar  origin,  these  two  being  the 
only  such  instances  found  in  the  entire  series.  The  supero-inferior  extent  of 
the  cellulae  ethmoidales  is  in  this  case  greater  than  usually  found  at  this  age. 
B.eth.,  Cellulse  bullae  ethmoidales;  Cel.eth.post.,  cellulse  ethmoidales  posterior; 
Fos.pterygopal.,  fossa  pterygopalatina;  Ost.max.acces.,  ostium  maxillare  acces- 
sorium;  Ost.max.,  ostium  maxillare;  Fos.sac.lacr.,  fossa  sacci  lacrimaHs;  Injund. 
eth.,  infundibulum  ethmoidale;   S. front.,  sinus  frontalis. 


THE    SINUS    MAXILLARIS 


93 


Hypopl-v. 


Ost.tubOLud. 


F.phar.Has. 


Fig.  34. — Specimen  From  a  Child  Eight  Years,  Eight  Months,  and  One 
Day  Old.  (Series  D,  No.  63.) 
Sagittal  section  cut  1  mm.  to  the  right  of  median  Hne.  Pneumatization  of 
the  sphenoid  bone  is  less  extensive  than  is  usually  found  at  this  age.  (Com- 
pare with  Figs.  27,  29,  and  31.)  S.front.,  Sinus  frontaUs;  Rec.sph.eth.,  recessus 
sphenoethmoidalis;  S.sph.,  sinus  sphenoidalis ;  Hypoph.,  hypophysis;  Ton. 
phar.,  tonsilla  pharyngea;  F.phar.bas.,  fascia  pharyngobasilaris;  Ost.tuh.aud., 
ostium  pharyngeum  tubse  auditivse. 


THE    SINUS   MAXILLARIS 


95 


S.irout 


Ost.froixt 
Cel.  iatuad 

Fos.se-c.  laLcr. 

Ost.max  - 

Sept.iT\a.x 


Fig.  35. — Specimen  From  a  Child  Eight  Years,  Eight  Months,  and  One 
Day  Old.  (Series  D,  No.  63.) 
Lateral  view  of  frontal,  ethmoidal,  and  maxillary  sinus  areas,  the  lateral 
portion  of  each  ha\'ing  been  removed  by  sagittal  cuts.  Note  that  the  sinus 
frontalis  developed  directly  from  the  infundibulum  ethmoidale.  Note  also 
the  incomplete  septa  in  the  sinus  maxillaris.  Cel.eth.ant.,  Cellulse  ethmoidales 
anterior;  Cel.eth.post.,  cellulae  ethmoidales  posterior;  N. optic,  nervous  opticus; 
Sept.max.,  septulse  maxillares;  Ost.max.,  ostium  maxillare;  Fos.sac.lacr., 
Fossa  sacci  lacrimalis;  Cel.infund.,  cellulse  infundibulares;  Ost.front.,  ostium 
frontale;  S. front.,  sinus  frontalis. 


THE    SINUS   MAXILLARIS 


97 


Ost.f  ro  at.  Ca.)^ 
Ost.-tro  n.t  Cb) 


Os-t.tv'b.aLUci 


Fig.  36. — Specimen  From  a  Child  Nine  Years,  One  Month,  and  Nine 
Days  Old.  (Series  D,  No.  64.) 
Incision  through  maxilla  is  3^  mm.  to  the  right  of  median  line;  in  the  frontal 
region  1  mm.  to  the  left,  and  through  the  body  of  the  sphenoid  is  5  mm.  to 
the  left  of  median  line.  The  anterior  portion  of  the  concha  media  and  a  small 
portion  of  the  frontal  bone  have  been  removed  to  show  the  structures  entering 
into  the  formation  of  the  lateral  nasal  wall,  and  also  the  location  of  the  ostia 
frontalia.  In  this  case  there  are  three  sinus  frontales — one  in  the  right  side 
and  the  two  in  the  left  side  here  illustrated.  Of  the  more  lateral  sinus  frontalis, 
only  the  ostium  is  shown  (Ost.  front.  (6) );  the  sinus,  however,  extends  to  the 
same  height  as  the  medial  one  shown  in  the  illustration.  Note  that  neither 
ostium  comes  into  direct  relation  to  the  infundibulum  ethmoidale.  In  the 
suprabuUar  furrow  ostia  of  bullar  cells  are  shown.  S. front.,  Sinus  frontalis; 
C.front.,  conchse  frontales;  Ost. tub. and.,  ostium  pharyngeum  tubse  auditivae; 
S.sph.,  sinus  sphenoidalis;  B.eth.,  bulla  ethmoidalis;  Proc.unc,  processus 
uncinatus;  Ost.front.(b),  ostium  of  the  lateral  sinus  frontalis;  Ost. front. (a), 
ostium  of  the  medial  sinus  frontalis. 


THE    SINUS   MAXILLARIS 


99 


Proc  un-c. 
ln,iu  n.a.e.-tK. 


Ld-m.  pa.py  r. 

Cel  .b.e-tK 
MArxlf  aorb 


S.TYva^  X. 


Fig.  37. — Specimen  From  a  Child  Nine  Years,  Ten  Months,  and  Nine- 
teen Days  Old.  (Series  D,  No.  65.) 
Anterior  view  of  coronal  section,  cut  20  mm.  posterior  to  the  nasion,  showing 
the  size  and  relations  of  the  sinus  maxillaris,  the  ostium  maxillare,  and  its 
manner  of  communication  with  the  infundibulum  ethmoidale,  the  bulla  eth- 
moidalis,  processus  uncinatus,  and  cellulae  ethmoidales  anterior.  Cr.gal.,  Crista 
galli;  Proc.unc,  processus  uncinatus;  Infund.eth.,  infundibulum  ethmoidale; 
Ost.max.,  ostium  maxillare;  S.max.,  sinus  maxillaris;  N.infraorb.,  nervus  in- 
fraorbitalis;  Cel.h.eth.,  cellula  bulla  ethmoidalis;  Lam. pap?/r.,  lamina  papyracea. 


THE    SINUS    MAXILLARIS 


101 


Ost.-tront 
C.m.ecl.cu-t   surfa.ce 


S.spK 


:)n.pKe>.r. 


^Ost.-tub.a-ucl. 


Fig.  38. — Specimen  From  a  Child  Ten  Years,  One  Month,  and  Seven 
Days  Old.  (Series  D,  No.  66.) 
Sagittal  section  1  mm.  to  the  left  of  the  median  line.  The  anterior  portion 
of  the  concha  media  and  a  portion  of  the  medial  wall  of  the  sinus  frontalis  have 
been  removed.  Note  that  sphenoidal  pneumatization  has  extended  beneath 
the  anterior  portion  of  the  sella  turcica.  S. front.,  Sinus  frontalis;  Proc.unc, 
processus  uncinatus;  B.eth.,  bulla  ethmoidalis;  C.inf.,  concha  inferior;  Ost. 
tuh.aud.,  ostium  pharyngeum  tubae  auditivae;  Ton.phar.,  tonsilla  pharyngea; 
S.sph.,  sinus  sphenoidalis;  C.supr.I,  concha  suprema  I;  C.sup.,  concha  su- 
perior;  C.med.,  concha  media;   Ost.front.,  ostium  frontale. 


THE    SINUS   MAXILLARIS 


103 


S-f  ron.t. 


Ost.  fron-t. 
Cel.b.etH. 

Ce-l.etK.pQst. 


Ca.M.q.senxt. 


A.c.a.r.ln.-t. 


Fig.  39. — Specimen  From  a  Child  Ten  Years,  Seven  Months,  and  Twenty- 
seven  Days  Old.  (Series  D,  No.  67.) 
Lateral  view  of  the  left  frontal,  ethmoidal,  and  maxillary  sinus  areas,  the 
lateral  portions  of  which  have  been  removed  by  sagittal  sections.  Note  the 
relations  of  the  cranial  nerves  to  that  portion  of  the  body  of  the  sphenoid 
which  forms  the  lateral  wall  of  the  sinus  sphenoidalis.  The  nervus  maxillaris 
is  0.9  mm.  lateral  to  the  sinus  sphenoidalis.  Ost.front.,  Ostium  frontale; 
Cel.b.eth.,  cellulse  bullae  ethmoidales;  Cel.eth.post.,  cellulse  ethmoidales  pos- 
terior; N.optic,  nervus  opticus;  N.oculom.,  nervus  oculomotorius;  N.troch., 
nervus  trochlearis;  Gang. semi.,  ganglion  semilunare  (Gasseri);  A. car. int., 
arteria  carotis  interna;  S.max.,  sinus  maxillaris;  Ost.max.,  ostium  maxillare; 
Infund.eth.,  infundibulum  ethmoidale;  Cel.infund.,  cellulae  infundibulares; 
Cel.front.,  cellula  frontalis;  S.front.,  sinus  frontalis. 


THE    SINUS   MAXILLARIS 


105 


S.trorvt 


M.s\Jp. 


M.  med 


K.iaf. — (4^ 


Ti_>berc.ulous    vjlcera-tlon. 


OSt.tUtD.dLOd. 


Fig.  40. — Specimen  From  a  Child  Eleven  Years  Old.  (Series  D,  No.  68.) 
Sagittal  section  showing  the  conchse  nasales,  the  sinus  sphenoidalis,  the 
septum  frontale,  and  the  portion  of  the  left  sinus  frontalis  extending  to  the 
right  of  the  median  line.  S.sph.,  Sinus  sphenoidalis;  Hypoph.,  hypophysis; 
Ost.tub.aud.,  ostium  pharyngeum  tubae  auditivae;  M.inf.,  meatus  inferior; 
M.med.,  meatus  medius;   M.sup.,  meatus  superior;   S.front.,  sinus  frontahs. 


THE    SINUS   MAXILLARIS 


107 


Cel.i  ro  wt 


Probe   in. 
Huct.aaL.laicr. 


Siront. 
Sept.  iroat. 


.eLfrorxt. 


"Fo5.  sa-c.  Id-cr. 


For.iatrdorb. 
eiTxi. 


Fig.  41. — Specimen  From  a  Child  Twelve  Years,  Nine  Months,  and 
Twelve  Days  Old.  (Series  D,  No,  69.) 
Anterior  view  of  a  coronal  section  cut  12  mm.  posterior  to  the  nasion,  to 
show  superior  and  lateral  extent  of  the  sinus  frontales,  also  the  relations  of  the 
cellulae  frontales.  The  frontal  sinuses  and  all  cells  shown  in  this  illustration 
have  their  ostia  medial  to  the  uncinate  processes.  Note  the  relations  of  the 
ductus  nasolacrimalis.  S.front.,  Sinus  frontalis;  Sept.front.,  septum  frontale; 
Cel.front.,  cellulae  frontales;  Fos.sac.lacr.,  fossa  sacci  lacrimalis;  For.infraorb., 
foramen  inf raorbitalis ;  Duct.na.lacr.,  ductus  nasolacrimalis. 


THE    SINUS    MAXILLARIS  109 

after  that  age  a  ridge  on  the  roof  of  the  sinus,  which  distinctly 
indicates  the  course  of  the  nerve  in  its  canal.  The  degree 
of  prominence  which  the  ridge  may  assume  varies  greatly 
in  the  different  specimens  (Figs.  25,  26,  42,  and  52).  In  the 
vast  majority  of  cases  there  is  thus  formed  a  complete 
osseous  canal  for  the  nervus  inf raorbitalis ;  but  in  some  few 
instances  its  osseous  structure  is  incomplete,  so  that  the 
mucosa  of  the  sinus  becomes  a  part  of  the  immediate  sup- 
port for  the  nerve. 

The  osseous  framework  of  the  medial  wall  of  the  sinus 
maxillaris  consists  of  the  thin  portion  of  the  corpus  maxillae 
surrounding  the  hiatus  maxillaris,  and  also  of  the  laminae 
from  contiguous  bones  partially  filling  in  the  hiatus.  The 
laminae,  which  form  the  incomplete  portion  of  the  wall,  are 
the  processus  maxillaris  and  the  processus  ethmoidalis 
conchae  nasalis  inferior,  the  pars  perpendicularis  ossis  pala- 
tina,  the  processus  uncinatus  ossis  ethmoidalis,  and  the  pos- 
tero-inferior  portion  of  the  os  lacrimale  (Fig.  56) .  With  the 
mucosa  intact,  the  interstices  between  these  laminae  are 
bridged  over,  leaving  normally  the  ostium  maxillare  as  the 
only  opening  between  the  sinus  and  the  nasal  cavity.  The 
wall  thus  covered  by  mucosa  usually  forms  a  rather  smooth 
surface  (Figs.  28,  45,  and  49),  but  in  some  cases  distinct 
ridges  may  be  produced  by  irregularities  in  the  underlying 
bone  (Fig.  30). 

The  ostium  maxillare  is  in  the  anterosuperior  portion  of 
the  medial  wall  of  the  sinus  maxillaris  (Figs.  39,  45,  and  49), 
and  is  the  point  of  communication  between  the  sinus  and 
the  infundibulum  ethmoidale  (Figs.  26,  37,  and  52).  The 
ostium  varies  from  a  narrow,  slit-like  opening  to  forms  oblong 
or  ovoid  in  outline.     The  average  diameters  of  the  ostia. 


110  THE    NASAL   ACCESSORY    SINUSES    IN    MAN 

as  found  in  cases  of  different  ages,  are  given  in  the  above 
table  of  measurements  of  the  sinus  maxillares.  The  rela- 
tions of  the  ostium  to  the  infundibulum  are  fairly  constant. 
The  opening  is  in  the  inferolateral  wall  of  the  infundibulum, 
the  situation  of  the  midpoint  of  the  ostium  corresponding 
approximately  to  the  anterior  portion  of  the  middle  third 
of  the  infundibulum. 

Communication  between  the  sinus  maxillaris  and  the 
meatus  medius  is  via  the  ostium  maxillare,  the  infundibulum 
ethmoidale,  and  the  hiatus  semilunaris  (Figs.  26,  37,  and 
53).  The  distance  between  the  ostium  maxillare  and  the 
hiatus  semilunaris  varies  in  adult  cases  from  4  to  12  mm., 
according  to  the  width  of  the  processus  uncinatus  and  also 
to  the  degree  of  the  medial  inclination  of  its  free  or  postero- 
superior  portion. 

Through  the  anterior  portion  of  the  infundibulum  the 
sinus  maxillaris  is  brought  into  close  relationship  with  the 
cellulse  infundibulares,  and  to  all  sinus  front  ales  having  their 
ostia  lateral  to  the  processus  uncinatus  (Figs.  35,  49,  and 
52).  In  this  series  the  ostia  of  39.6  per  cent,  of  the  frontal 
sinuses  were  so  located.  These  relations  are  important 
when  dealing  with  suppurative  conditions  in  this  area;  also, 
as  observed  by  Keen,  in  those  cases  of  sarcoma  of  the  maxilla 
in  which  a  portion  of  the  growth  has  extended  toward  or 
into  the  frontal  region,  partially  or  completely  fiUing  the 
infundibulum,  the  cellulse  infundibulares,  or  even  the  sinus 
frontalis. 

Duplication  of  the  ostium  maxillare  is  a  condition  in  which 
the  sinus  maxillaris  has  two  ostia,  both  of  which  communicate 
with  the  infundibulum  ethmoidale.  Such  a  condition  was 
present  in  only  one  specimen  in  this  series  (Fig.  54) .     Dupli- 


THE    SINUS   MAXILLARIS  111 

cation  of  the  ostium  is,  we  believe,  due  to  a  developmental 
process  similar  to  that  producing  the  ostia  maxillaria  acces- 
soria,  which  will  be  considered  below,  differing  only  in  that 
accessory  ostia  are  located  posterior  to  the  infundibulum 
and  thus  communicate  directly  with  the  meatus  medius. 

Schaeffer  found  the  primitive  maxillary  pouch  duplicated 
in  some  of  his  fetal  specimens,  and  suggested  that  this  may 
explain  some  of  the  duplications  of  the  ostium  maxillare  of 
the  adult  sinus,  the  two  pouches  fusing  distally,  forming  a 
single  cavity  with  duplicated  ostia.  To  us,  however,  this 
does  not  seem  probable,  since  we  find  that  accessory  sinuses 
which  have  developed  from  separate  ostia  do  not  directly 
communicate,  except  in  instances  where  the  intervening  wall 
has  been  destroyed  by  a  suppurative  process.  In  the  de- 
velopment of  accessory  sinuses  the  pouching  mucosa  rests 
upon  a  layer  of  compact  bone  as  the  process  of  pneumatiza- 
tion  extends  into  the  body  of  the  bone — whether  it  be  the 
maxillary,  the  frontal,  or  the  sphenoid  bone.  The  layer 
of  compact  bone  advances  as  the  process  of  resorption  goes 
on  in  the  underlying  cancellous  bone.  When  two  advancing 
layers  of  compact  bone  are  brought  into  contact  by  the  re- 
sorption of  the  intervening  cancellous  bone,  resorption  ceases 
and  a  permanent  layer  of  compact  bone  remains  between 
the  layers  of  mucoperiosteum  lining  the  sinus  cavities.  Ir- 
regularities in  the  rate  of  resorption  of  the  cancellous  bone 
surrounding  any  individual  sinus  may  be  of  a  character  in 
which  the  advancing  layers  of  compact  bone  surrounding 
different  recesses  of  that  sinus  are  brought  into  contact, 
in  which  case  a  ridge  or  an  incomplete  septum  persists. 
The  sinus  maxillaris  in  Fig.  35,  and  the  superior  portion  of 
the  left  sinus  frontalis  in  Fig.  52,  show  incomplete  septa 


112  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

formed  in  this  way.  In  view  of  these  facts  we  are  inchned 
to  beUeve  that  if  two  pneumatization  pouches  were  to  ad- 
vance into  the  maxilla  the  result  would  be  a  double  maxillary 
sinus,  instead  of  the  only  remains  being  simply  the  dupli- 
cated ostia.  In  rare  instances  double  maxillary  sinuses  are 
present,  but  we  have  found  no  report  of  a  case  in  which  both 
of  the  ostia  opened  into  the  infundibulum.  Double  maxil- 
lary sinuses  will  be  considered  later. 

The  ostium  maxillare  accessorium  (Figs.  27,  30,  33,  and 
48)  is  an  opening  which  is  sometimes  found  in  the  medial 
wall  of  the  sinus  maxillaris,  forming  an  additional  communi- 
cation with  the  meatus  nasi  medius.  Such  openings  vary 
from  0.5  to  15  mm.  in  diameter,  and  are  most  frequently 
situated  at  a  point  5  to  10  mm.  above  the  superior  border 
of  the  concha  inferior,  at  the  junction  of  its  posterior  and 
middle  thirds.  The  majority  of  observers  have  found  ac- 
cessory ostia  present  in  about  10  per  cent,  of  adult  cases. 
Schaeffer,  in  80  cases,  found  accessory  ostia  in  43  per  cent, 
of  them.  In  my  own  series,  114  lateral  nasal  walls  from  cases 
between  four  and  twenty-four  years  of  age  show  accessory 
ostia  in  15  per  cent,  of  cases.  The  youngest  specimen  show- 
ing an  accessory  ostium  was  from  a  child  four  years,  three 
months,  and  two  days  old;  thus  cases  under  four  years  of 
age  were  excluded  in  estimating  the  frequency  of  its  occur- 
rence. Two  accessory  ostia  (Fig.  48)  were  present  in  two 
specimens. 

The  ostium  maxillare  accessorium  evidently  has  no  em- 
bryologic  significance  in  its  development;  neither  can  it 
be  considered  as  a  compensatory  opening  which  has  de- 
veloped because  of  a  deficiency  in  the  size  of  the  normal 
ostium  maxillare,  for  in  no  case  showing  the  presence  of  an 


THE    SINUS   M AXILLARIS  113 

accessory  ostium  was  the  normal  ostium  found  to  be  smaller 
than  the  average  for  the  given  age.  The  process  of  its  de- 
velopment is  apparently  a  progressive  thinning  of  the  medial 
wall  of  the  sinus  at  a  point  where  the  wall  is  naturally  thin, 
and  where  there  is  no  osseous  lamina  between  the  mucosa 
lining  the  sinus  and  that  lining  the  meatus  medius,  the  thin- 
ning continuing  until  an  actual  opening  through  the  mem- 
branes occurs.  In  a  great  majority  of  the  cases  in  which 
accessory  ostia  were  found  there  were  pathologic  processes 
present  to  give  evidence  of  lowered  vitality  in  those  im- 
mediate areas,  and  in  several  instances  the  situation  of 
mucous  cysts  was  such  as  to  interfere  with  the  normal  circu- 
lation of  the  medial  sinus  wall. 

In  76  per  cent,  of  cases  showing  accessory  ostia  there  were 
mucous  cysts  (retention  cysts)  in  the  mucosa  lining  the 
medial  walls  of  the  sinus  maxillares  (Figs.  30  and  33) .  The 
cysts  varied  from  0.5  to  9  mm.  in  diameter.  In  19  per  cent, 
of  cases  the  mucosa  was  distinctly  granular  in  appearance, 
but  showed  no  cysts.  In  the  remaining  5  per  cent,  of  cases 
the  surrounding  mucosa  was  apparently  normal. 

The  cases  in  this  series  suggest  the  possibility  of  pulmonary 
tuberculosis  having  some  influence  upon  the  frequency  of 
the  occurrence  of  the  ostia  accessoria,  but  we  do  not  regard 
the  series  as  sufficiently  large  to  establish  this  relationship 
as  a  definite  fact.  However,  we  submit  the  observation 
that  in  114  lateral  nasal  walls  from  cases  between  four  and 
twenty- two  years  of  age,  15  per  cent,  showed  the  presence 
of  accessory  ostia.  Of  the  114  specimens,  42  per  cent,  were 
from  patients  who  had  died  from  pulmonary  tuberculosis. 
In  the  specimens  from  tuberculous  cases,  37.5  per  cent,  had 


114  THE    NASAL   ACCESSORY   SINUSES   IN   MAN 

accessory  ostia,  while  in  all  other  specimens  accessory  ostia 
were  present  in  only  7.7  per  cent,  of  cases. 

Zuckerkandl  regarded  pressure  from  septal  spurs  or  from 
enlarged  middle  conchae  as  occasional  factors  in  the  produc- 
tion of  ostia  accessoria.  In  this  series  no  case  with  an 
accessory  ostium  showed  these  conditions  to  be  present  in  a 
sufficient  degree  to  exert  any  apparent  influence  on  the  de- 
velopment of  an  accessory  opening. 

The  superior  wall,  or  roof,  of  the  sinus  maxillaris  is  a  thin 
plate  of  bone  (its  superior  surface  being  the  facies  orbitalis 
maxillae),  the  central  and  posterior  portions  of  which  vary 
from  0.5  to  1.5  mm.  in  thickness.  Along  two  ridges  which 
project  into  the  sinus  and  near  the  anterior  margin,  the 
bone  is  usually  of  a  greater  thickness.  The  more  constant 
of  the  two  ridges  is  the  one  which  forms  the  inferior  wall  of 
the  above-mentioned  canalis  infraorbitalis  (Figs.  25,  26, 
42,  and  52).  The  second  ridge  is  well  marked  in  the  major- 
ity of  cases,  and  extends  laterally  along  the  roof  from  the 
posterior  margin  of  the  ostium  maxillare  (Figs.  33,  39,  45, 
and  54).  Its  prominence  decreases  as  it  passes  laterally, 
and  usually  disappears  just  medial  to  the  canalis  infra- 
orbitalis. 

Not  uncommonly  the  cellulae  ethmoidales,  in  their  infero- 
lateral  development,  extend  for  a  short  distance  (2  to  4  mm.) 
into  the  roof  of  the  sinus ;  and  in  rare  instances  the  develop- 
ment may  be  such  that  an  aberrant  posterior  ethmoidal 
cell  occupies  the  area  which  would  ordinarily  be  the  postero- 
superior  angle  of  the  sinus  maxillaris  (Fig.  50). 

The  posterior  wall  of  the  sinus  maxillaris  is  the  most 
regular  of  all  its  boundaries.  In  an  average  case  it  varies 
from  0.5  to  3  mm.  in  thickness,  the  portions  near  the  angles 


THE    SINUS   MAXILLARIS 


115 


S.ma.x 


Septa.1  rtdcje 


C.lnf. 


Fig.  42. — Specimen  From  a  Child  Thirteen  Years,  Six  Months,  and  Nine- 
teen Days  Old.  (Series  D,  No.  72.) 
Posterior  view  of  a  coronal  section  31  mm.  posterior  to  the  nasion,  showing 
maxillary  sinuses,  bullar  and  posterior  ethmoidal  cells.  Note  the  influence 
of  septal  ridge  and  deviation  of  septum  upon  the  form  of  each  concha  media; 
also  upon  the  degree  of  medial  inclination  of  each  processus  uncinatus,  thus 
producing  a  marked  difference  in  the  width  of  the  hiatus  semilunaris  and  the 
infundibulum  ethmoidale  of  each  side.  Cr. gal.,  Crista,  galU;  Cel.eth.post., 
cellulae  ethmoidales  posterior;  C.med.,  concha  media;  Cel.b.eth.,  cellula  bullae 
ethmoidalis;  Proc.unc,  processus  uncinatus;  C.inf.,  concha  inferior;  S.max., 
sinus  maxillaris;   C.sup.,  concha  superior. 


THE    SINUS   MAXILLARIS 


117 


(cot  auria-ces") 
C.l  rvl 


Toa.pKa-rj 


Os-t.tuh.A-ud. 


Fig.  43. — Specimen  Fourteen  Years  and  Seven  Months  Old.     (Series  D, 

No.  73.) 
Sagittal  section,  cut  4  mm.  to  the  right  of  the  median  Hne,  thus  removing 
the  medial  portions  of  the  concha  inferior  and  concha  media,  and  the  medial 
anterosuperior  portions  of  the  concha  superior  and  concha  suprema  I.  The 
relations  of  the  structures  forming  the  lateral  nasal  wall  and  the  positions  of  the 
ostia  of  the  cellulae  ethmoidales  are  thus  clearly  shown.  1.,  Probe  through 
ostium  frontale;  B.eth.,  bulla  ethmoidahs;  Cel.eth.post.,  cellulse  ethmoidales 
posterior;  2.,  probe  through  ostium  of  most  posterior  ethmoidal  cell;  S.sph., 
sinus  sphenoidalis;  Hypoph.,  hypophysis;  C.sitpr. 7,  concha  suprema  I;  C.sup., 
concha  superior;  Ton.phar.,  tonsilla  pharyngea;  Ost.tuh.aud.,  ostium  pharyn- 
geum  tubse  auditivse ;  Cw/.,  concha  inferior;  Cmed.,  concha  media;  H.semi., 
hiatus  semilunaris;  Proc.unc,  processus  uncinatus. 


THE    SINUS   MAXILLARIS 


119 


CArvt 


Fls.  orb.s^jp. 


5.mei.x. 


Ton.  phe^r. 


Fig.  44. — Specimen  Fifteen  Years  and  Five  Months  Old.     (Series  D,  No. 

75.) 
Coronal  section  cut  44  mm.  posterior  to  nasion,  showing  posterior  portions 
of  the  conchse  and  the  posterior  walls  of  maxillary  sinuses.  Fis.orb.sup., 
Fissura  orbitalis  superior;  S.max.,  sinus  maxillaris;  Ton.phar.,  tonsilla  pharyn- 
gea;  C.inf.,  concha  inferior;  C.med.,  concha  media;  C.sup.,  concha  superior; 
C.supr.I,  concha  suprema  I. 


THE    SINUS   MAXILLARIS 


121 


S.troat. 


Cel.ettx.p  ost. 
M.o  ptlc._ 
N.ocuiom. 
N.tro 


Cel.-frorvt 
^In-furx-d.  e 

Boot.na.l 


Artcar.lat 
ra  a,  (5.  semi 


Ost.naaix 


Art.ccLr.lr\l 


5.  spK 


Fig.  45. — Specimen  Fifteen  Years,  Nine  Months,  and  Twenty-six  Days 
Old.  (Series  D,  No.  76.) 
Lateral  portions  of  the  frontal,  ethmoidal,  maxillary,  and  sphenoidal  areas 
have  been  removed  by  sagittal  incisions.  Note  the  marked  extent  of  the  sinus 
sphenoidaHs  into  the  pterygoid  process.  The  ridge  which  is  seen  on  the  floor 
of  the  sinus  sphenoidaHs  overiies  the  nervus  canahs  pterygoidei  (Vidii).  The 
sinus  maxillaris  extends  11  mm.  below  the  level  of  the  nasal  floor.  S. front., 
Sinus  frontahs;  Cel.front.,  cellulse  frontales;  Cel.infund.,  cellulse  infundib- 
ulares;  Infund.eth.,  infundibulum  ethmoidale;  Dud.na.lacr.,  ductus  naso- 
lacrimalis;  Osf.maa;.,  ostium  maxillare;  S.sph.,  the  portion  of  sinus  sphenoidaHs 
extending  into  the  pterygoid  area;  Art.car.int.,  arteria  carotis  interna; 
Gang. semi.,  ganglion  semilunare;  A.anom.,  anomalous  branch  of  carotid 
artery;  N.troch.,  nervus  trochlearis;  N.oculom.,  nervus  oculomotorius;  N. 
optic,  nervus  opticus;  Cel.eth.post.,  cellulse  ethmoidales  posterior;  Cel.b.eth., 
cellulse  bullse  ethmoidales. 


& 


THE    SINUS   MAXILLARIS 


123 


CeLconcha 


46. — Specimen  Fifteen  Years,  Nine  Months,  and  Twenty-six  Days 
Old.  (Series  D,  No.  76.) 
Lateral  view  of  this  specimen  is  shown  in  Fig.  45.  Sagittal  section,  showing 
the  sinus  sphenoidalis  and  a  portion  of  the  lateral  nasal  wall.  There  was  in 
this  case  a  marked  deviation  of  the  septum  nasi  toward  the  left,  and  a  com- 
pensatory increase  in  the  size  of  the  concha  media.  Note  the  presence  of  the 
cellulse  conchales.  The  anterior  conchal  cell  has  its  origin  as  an  extension 
from  a  posterior  ethmoidal  cell,  just  anterior  to  the  superior  meatus,  while  the 
posterior  conchal  cell  developed  from  the  posterior  portion  of  the  suprabullar 
furrow.  1,  Probe  through  ostium  of  the  anterior  conchal  cell;  2,  probe 
through  ostium  of  the  posterior  conchal  cell;  C.sup.,  concha  superior;  C.swpr.I, 
concha  suprema  I;  S.sph.,  sinus  sphenoidalis;  Ton.phar.,  tonsilla  pharyngea; 
Cmed.,  concha  media;  C.i/i/.,  concha  inferior;  C el. conchales,  cellulse  conchales. 


THE    SINUS   MAXILLARIS 


125 


5.1  T  o  ixt 


CGl.iaf  uad? 


Duct.aeL.la-Cr. 


Ost.max- 


rauoo  us  cysts 


Ld^m  l£).-t. 


Fig.  47. — Specimen  Sixteen  Years,  Five  Months,  and  Twenty-one  Days 
Old.  (Series  D,  No.  79.) 
Lateral  view  of  frontal,  ethmoidal,  maxillary,  and  a  portion  of  the  sphenoidal 
areas.  Maxillary  sinus  contains  mucous  cysts.  The  ridge  which  is  seen  on 
the  floor  of  the  sphenoidal  sinus  overlies  the  nervus  canalis  pterygoidei  (Vidii). 
Note  the  extent  of  sphenoidal  sinus  into  the  pterygoid  area,  also  the  extent  of 
an  infundibular  cell  far  into  the  frontal  process  of  the  maxilla.  Cel.b.eth., 
Cellulse  bullae  ethmoidales;  Cel.eth.post.,  cellulse  ethmoidales  posterior;  S. 
sph.,  sinus  sphenoidalis;  Lam.lat.,  lamina  lateralis  processus  pterygoidei; 
Ost.max.,  ostium  maxillare;  Duct.na.lacr.,  ductus  nasolacrimalis;  Cel.infund., 
cellulae  infundibulares;  S. front.,  sinus  frontahs. 


THE    SINUS   MAXILLARIS 


127 


.tron.t.(le-tO 


^ 


P  roc.u  n.  c. 
C.lat 


-Ton-.-p 


Ost.Tnai.x.aiccas. 


Fig.  48. — Specimen  Seventeen  Years  Old.     Sagittal  Section  1  mm.  to  the 

Left  of  the  Median  Line.     The  Septum  Nasi  and  the  Anterior  Portion 

OF  THE  Concha  Media  Have  Been  Removed.     (Series  D,  No.  83.) 

Note  the  presence  of  two  accessory  ostia  maxillaria.     Similar  ostia  were 

found  opening  into  the  left  sinus  maxillaris  of  this  case.     Both  sinus  maxillares 

contained  mucous  cysts  near  the  accessory  ostia.     1,  Probe  in  ostium  frontale; 

2  and  3,  probes  in  the  ostia  of  cellulse  ethmoidales  posterior;  4,  probe  through 

ostium  sphenoidale;    H.semi.,  hiatus  semilunaris;    B.eth.,  bulla  ethmoidalis; 

C.supr.I,  concha  suprema  I;    S.sph.,  sinus  sphenoidalis;    Ton.phar.,  tonsilla 

pharyngea;  Ost.max.acces.,  ostia  maxillaria  accessoria;  C.inf.,  concha  inferior ; 

C.med.,  concha  media;  Proc.unc,  processus  uncinatus;  S.front.,  sinus  frontalis 

(medial  portion  of  left  sinus  extending  slightly  to  the  right  of  median  line) . 


THE    SINUS   MAXILLARIS  129 

being  thicker  than  the  central  area.  The  medial  portion  of 
the  wall  forms  the  anterior  boundary  of  the  fossa  pterygo- 
palatina  (Fig.  33). 

The  anterior  or  facial  wall  of  the  sinus  maxillaris  varies 
from  2  to  5  mm.  in  thickness,  and  is,  with  the  exception  of 
that  portion  of  the  floor  which  is  formed  by  the  alveolar 
process,  the  thickest  and  the  strongest  of  all  the  walls.  It 
faces  in  an  anterolateral  direction,  with  a  varying  antero- 
inferior obliquity.  This  obliquity,  which  depends  upon  the 
degree  of  approximation  of  the  inferior  portion  of  the  wall 
toward  the  posterior  wall,  produces  the  variations  in  the 
number  of  teeth  which  are  in  relation  to  the  sinus  floor,  and 
greatly  influences  the  capacity  of  the  sinus.  The  anterior 
surface  presents,  below  the  infra-orbital  margin,  the  foramen 
infraorbitale,  beneath  which  is  a  variable  depression,  the 
fossa  canina  (Fig.  55). 

The  inferior  wall  of  the  pyramid,  the  floor  of  the  sinus 
maxillaris,  is  formed  near  the  medial  wall  by  the  processus 
alveolaris,  and,  more  laterally,  by  the  well-rounded  angle 
produced  by  the  approximation  of  the  inferior  portions  of 
the  anterior  and  posterior  walls. 

The  floor  of  the  sinus  maxillaris,  in  all  stages  of  its  de- 
velopment, is  in  close  relation  to  the  teeth  (Figs.  17,  21,  28, 
30,  and  33),  and  the  increase  in  the  vertical  diameter  of 
the  sinus  is  found  to  be  much  more  of  a  process  of  expansion 
as  the  body  of  the  maxilla  increases  in  size,  than  it  is  one 
of  resorption  of  cancellous  bone  previously  occupying  the 
area. 

The  number  of  teeth,  the  roots  of  which  are  in  close  rela- 
tion to  the  floor  of  the  sinus,  shows  marked  variations  (Figs. 
45,  47,  50,  54,  and  55).  However,  the  typical  floor  may  be 
9 


130  THE   NASAL   ACCESSORY   SINUSES   IN   MAN 

considered  as  one  which  overHes  the  roots  of  all  the  molars 
and  the  posterior  portion  of  the  second  premolar.  In  many 
cases  only  the  molars  come  into  close  relation,  and  in  a  few 
cases  only  the  second  and  third  molars  are  beneath  the  floor. 
It  is  a  very  extensive  floor,  which  advances  so  far  anteriorly 
as  to  overlie  the  first  premolar,  and  in  this  series  no  case  was 
found  in  which  the  root  of  the  canine  was  in  relation  to  the 
floor.  In  a  few  of  the  larger  sinuses,  however,  the  root  of 
the  canine  extended  well  up  into  the  anterior  wall  of  the 
sinus. 

Regardless  of  the  extent  of  the  irregularities  in  the  floor 
of  the  sinus  produced  by  resorption  of  the  cancellous  bone 
surrounding  the  roots  of  the  teeth,  in  no  instance  was  the 
mucosa  lining  the  sinus  found  in  direct  contact  with  the  root 
of  a  healthy  tooth.  In  all  normal  cases  a  thin  layer  of  com- 
pact bone  was  present  between  the  roots  of  the  tooth  and 
the  mucosa;  but  in  a  few  instances,  where  there  had  been 
abscess  formation  at  the  root  of  a  tooth,  this  intervening 
plate  of  bone  had  been  destroyed,  thus  allowing  the  root  to 
project  into  the  sinus  cavity,  in  direct  contact  with  the  over- 
lying mucosa. 

Besides  the  recesses  produced  by  the  ridges  on  the  alveolar 
surface,  pockets  may  be  formed  by  osseous  projections  on  the 
anterior,  or  less  frequently  on  the  posterior,  wall,  or  by  folds 
of  mucosa  independent  of  any  irregularity  in  the  underlying 
bone,  as  found  in  the  posteromedial  angle  of  the  sinus  shown 
in  Fig.  47.  Osseous  ridges  may,  in  rare  instances,  extend 
sufficiently  far  toward  the  central  portion  of  the  sinus  as  to 
form  incomplete  septa,  or  septulse  (Fig.  35).  Such  forma- 
tions have  no  embryologic  significance,  and  are  entirely 
due  to  irregularity  in  the  process  of  resorption.     Ridges  and 


THE    SINUS   M AXILLARIS  131 

folds  of  any  of  the  above-mentioned  varieties  probably 
assume  an  important  role  from  a  practical  viewpoint,  only 
in  the  presence  of  suppurative  conditions  within  the  sinus, 
when,  the  recesses  or  pockets  make  the  thorough  cleansing  of 
the  cavity  more  difficult. 

A  few  cases  have  been  reported  in  which  there  was  a  com- 
plete osseous  septum  dividing  the  sinus  maxillaris  into  two 
distinct  cavities,  each  having  its  independent  ostium  com- 
municating with  the  nasal  fossa.  According  to  Zuckerkandl, 
the  anterior  sinus,  in  such  cases,  communicates  with  the 
infundibulum  ethmoidale  through  the  normal  ostium  maxil- 
lare,  while  the  posterior  sinus  communicates  with  the 
meatus  superior.  Thus  it  is  seen  that  the  posterior  sinus 
is  in  reality  an  aberrant  posterior  ethmoidal  cell  which  in- 
vaded the  body  of  the  maxilla  and  there  developed  exten- 
sively. In  this  series  no  such  development  was  found  suffi- 
ciently extensive  to  justify  terming  it  a  double  sinus;  but 
in  one  instance  (Fig.  50)  such  an  aberrant  posterior  ethmoidal 
cell  is  shown,  and  indicates  the  manner  in  which  greater 
pneumatization  by  such  a  cell  would  produce  a  double 
maxillary  sinus. 


THE  SINUS  FRONTALIS 

The  areas  from  which  the  sinus  frontalis  may  have  its 
origin  were  considered  above  in  discussing  the  development 
of  the  cellulse  ethmoidales  anterior.  (See  pp.  45-6,  53-4.) 
We  found  that  during  the  fourth  month  of  fetal  life  there  are 
two  expansions  usually  demonstrable  in  the  anterosuperior 
portion  of  the  meatus  medius.  The  expanding  areas  are  sep- 
arated by  the  anterior  attachment  of  the  processus  uncinatus. 
The  recess  beneath  the  anterosuperior  attachment  of  the 
concha  media  and  medial  to  the  processus  uncinatus  is 
termed  the  recessus  conchalis.  The  recess  lateral  to  the 
anterior  portion  of  the  processus  uncinatus  is  termed  the 
recessus  infundibularis,  being  the  anterosuperior  termination 
of  the  infundibulum  ethmoidale.  From  the  recessus  con- 
chalis the  cellulse  front  ales  develop  between  the  conchse 
frontales  and  between  the  conchse  and  the  walls  of  the  recess, 
while  from  the  recessus  infundibularis  the  cellulse  infundib- 
ulares  have  their  origin.  A  sinus  frontalis  may  develop 
as  an  anterosuperior  extension  of  a  cell  originating  from 
either  of  these  two  recesses,  as  a  direct  extension  of  the  in- 
fundibulum ethmoidale,  as  a  direct  extension  of  a  recessus 
conchalis  in  which  no  frontal  cells  have  developed,  or,  in 
rare  instances,  as  an  extension  from  a  cell  originating  in  the 
suprabullar  furrow. 

Although  the  primitive  recessus  conchalis  and  the  recessus 
infundibularis  are  usually  demonstrable  during  the  fourth 
fetal  month,  and  distinct  cellulse  ethmoidales  anterior  de- 

132 


THE    SINUS    FRONTALIS  133 

velop  during  the  latter  months  of  fetal  life,  yet,  in  the  average 
case,  one  cannot  say  definitely  which  of  the  extending  proc- 
esses of  pneumatization  represents  the  primitive  sinus 
frontalis  until  after  the  sixth  month  of  postnatal  life.  In 
some  specimens  the  probable  route  of  development  can  be 
determined  with  a  fair  degree  of  certainty  at  the  time  of 
birth  or  shortly  thereafter  (Figs.  17  and  20),  while  in  other 
cases  the  distinct  beginning  of  a  sinus  frontalis  is  not  de- 
monstrable until  near  the  end  of  the  first  year. 

From  whichever  of  these  sources  a  frontal  sinus  may  have 
its  origin,  the  process  of  pneumatization  gradually  extends 
from  that  portion  of  the  anterior  ethmoidal  area  toward  and 
into  the  inferior  portion  of  the  frontal  bone.  The  sinus, 
surrounded  as  it  is  by  a  thin  lamina  of  compact  bone,  then 
advances  toward  the  ascending  portion  of  the  frontal  bone, 
advancing  as  the  cancellous  bone  is  resorbed.  This  rate  of 
resorption,  in  an  average  case,  is  such  that  the  sinus  begins 
its  ascent  into  the  vertical  portion  of  the  bone  during  the 
second  year,  and  in  the  third  year  is  3.8  mm.  above  the  level 
of  the  nasion. 

As  the  sinus  frontalis  advances  into  the  vertical  portion  of 
the  bone,  its  posterior  wall  is  always  thin  and  is  composed 
almost  entirely  of  compact  bone,  while  the  anterior  wall,  as 
found  in  the  different  specimens,  varies  greatly  in  its  thick- 
ness and  usually  contains  a  considerable  amount  of  diploe. 

In  the  following  table  we  have  given  the  average  diameters 
and  the  level  at  which  the  ostia  frontalia  were  found,  the 
origin  of  the  sinuses,  the  thickness  of  the  walls,  the  level 
reached  by  the  superior  border  of  the  sinus,  and  the  vertical, 
lateral,  and  anteroposterior  diameters  of  the  average  sinus 
as  found  in  the  given  number  of  cases  at  the  various  ages. 


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135 


136  THE   NASAL   ACCESSORY   SINUSES   IN   MAN 

All  measurements  are  given  in  millimeters.  The  level  of  the 
ostia  and  the  superior  level  of  the  sinuses  were  in  all  cases 
measured  from  the  level  of  the  nasion.  Thus  measurements 
preceded  by  a  minus  sign  indicate  that  the  average  level  was 
the  given  distance  inferior  to  the  nasion,  while  those  preceded 
by  a  plus  sign  indicate  the  given  distance  superior  to  the 
nasion. 

The  resorption  of  the  diploe  in  the  vertical  portion  of  the 
frontal  bone  is  seldom  such  as  to  make  the  sinuses  of  the  two 
sides  quite  symmetric.  The  general  outline  of  the  sinuses 
often  suggests  an  attempt  at  symmetry,  although  one  or 
more  of  the  diameters  may  show  considerable  variation. 
Not  uncommonly,  however,  the  two  sinuses  are  of  an  entirely 
different  form.  Irregularity  in  the  rate  of  resorption  on  the 
two  sides  often  produces  a  deviation  of  the  septum  frontale. 
The  position  of  the  septum  frontale  is,  in  the  great  majority 
of  cases,  median  at  its  inferior  portion,  but  in  a  few  instances 
this  portion  showed  variations  of  from  2  to  6  mm.  from  the 
median  line.  The  superior  portion  of  the  septum,  however, 
usually  shows  a  slight  deviation  to  one  side  or  the  other, 
the  deviation  being  away  from  the  more  rapidly  developing 
sinus.  Occasionally  a  case  is  found  in  which  one  of  the 
sinuses  is  poorly  developed  and  the  sinus  from  the  other  side 
has  developed  so  far  past  the  median  line  that  the  resulting 
deviation  of  the  septum  is  such  that  it  forms  a  part  of  the 
anterior  wall  of  the  deficiently  developed  sinus.  However, 
in  cases  where  the  interfrontal  suture  persisted  (metopic 
skulls),  no  instance  was  found  in  which  a  sinus  had  extended 
past  the  median  line,  regardless  of  the  extent  of  pneumatiza- 
tion  on  the  opposite  side. 

In  101  cases  (202  frontal  sinus  areas)  having  the  mucosa 


THE    SINUS   FRONTALIS 


137 


S.fron-t. ^ 


Ost.troat: 
Z-eLLafun-d 

uct.rva..latcr. 


S.maLX 


A  ca-r.  L 


Tub.e^ud. 


Fig.  49. — Specimen,  Eighteen  Years,  Eleven  Months,  and  Ten  Days  Old. 

(Series  D,  No.  85.) 
Lateral  view  of  the  frontal,  ethmoidal,  maxillary,  and  a  portion  of  the  sphe- 
noidal areas.  Sinus  frontalis  developed  from  an  infundibular  cell.  Note 
that  the  ostium  frontale  is  not  in  the  most  inferior  portion  of  the  floor  of  the 
sinus.  Cel.b.eth.,  Cellulse  bullae  ethmoidales;  Cel.eth.post.,  cellulse  ethmoidales 
posterior;  Os^.sp/i.,  ostium  sphenoidale;  >S.sp/?,.,  sinus  sphenoidalis;  A. car. int., 
arteria  carotis  interna;  N.abduc,  nervus  abducens;  N.max.,  nervus  maxil- 
laris;  Tub.aud.,  tuba  auditiva  (Eustachii);  S.max.,  sinus  maxillaris;  1, 
probe  through  ostium  maxillare;  Duct.na.lacr.,  ductus  nasolacrimalis;  Cel. 
infund.,  cellula  infundibularis;  Ost.front.,  ostium  frontale;  S.front.,  sinus 
frontahs. 


THE    SINUS    FRONTALIS 


139 


S.  treat. - 


Cel.laiund: 
In-f  uacl.G  t  K 


Cel.etK.post 
Canberra  a 


trock. 


^^f^y    r  GiCnqser 


S.rTLd.x 


Fig.    50. — Specimen    Nineteen    Years    and    Twenty-eight   Days    Old. 

Lateral  View  of  Frontal,  Ethmoidal,  and  Maxillary  Areas.     (Series 

D,  No.  86.) 

Note  presence  of  an  aberrant  ethmoidal  cell  which  has  invaded  the  postero- 
superior  portion  of  the  maxilla.  The  ostium  of  this  cell  is  in  the  midportion 
of  the  lateral  wall  of  the  meatus  superior.  When  this  type  of  development  is 
more  extensive,  a  "double  maxillary  sinus"  is  formed,  as  described  by  Zucker- 
kandl.  Cel.b.eth.,  Cellulse  bullae  ethmoidales;  Cel.eth.post.,  cellulse  ethmoidales 
posterior;  N.opHc,  nervus  opticus;  N.abduc,  nervus  abducens;  N.oculom., 
nervus  oculomotorius;  N.troch.,  nervus  trochlearis;  Gang.semi.,  ganglion 
semilunare;  S.max.,  sinus  maxillaris;  Cel.eth.post.  (aberrant),  aberrant  cellula 
ethmoidalis  posterior;  Infund.eth.,  infundibulum  ethmoidale;  Cel.infuncL, 
cellula  infundibularis;  S. front.,  sinus  frontalis. 


THE    SINUS    FRONTALIS 


141 


S.t  rorvt 


Ost.-froixt. 
Cel.f  roat 


H.semL. 
P  roc.u  rvc 


C.nn.ed.Ccut  swrta^c-e) 
C .  s  u  p. 
c.  supr.I. 
Os-t.spK. 

S.  sph. 


C.  I  ai 


Fig.  51. — Specimen  Nineteen  Years,  Seven  Months,  and  Fifteen  Days 
Old.  (Series  D,  No.  88.) 
Median  sagittal  section.  The  anterior  portion  of  the  concha  media  and  a 
portion  of  the  frontal  bone  have  been  removed  to  show  the  anterolateral  nasal 
wall.  The  hiatus  semilunaris  is  in  this  instance  unusually  short.  B.eth., 
Bulla  ethmoidalis;  C.med.,  concha  media  (cut  surface);  C.sup.,  concha  su- 
perior; C.supr.I,  concha  suprema  I;  Ost.sph.,  ostium  sphenoidale;  S.sph., 
sinus  sphenoidalis;  C.inf.,  concha  inferior;  Proc.unc,  processus  uncinatus; 
H.semi.,  hiatus  semilunaris;  Cel.front.,  cellulae  frontales;  Ost.front.,  ostium 
frontale;  S. front.,  sinus  frontalis. 


THE    SINUS    FRONTALIS 


143 


S.tvont 


aUontCnvedUl) 


S.troixt.Clatera.l') 


Cr.c^  Al. — -^^ 


S.rrcatx.- 


"PToc.unc, 


Fig,  52. — Specimen  Twenty  Years  and  Five  Months  Old.     (Series  D, 

No.  90.) 
Posterior  view  of  a  coronal  section  18  mm.  posterior  to  the  nasion.  The 
posterior  walls  of  the  sinus  have  been  removed  to  show  the  relations  of  the 
sinuses  and  their  ostia.  Note  that  on  the  right  side  there  are  two  distinct 
sinus  frontales  present.  The  more  medial  of  these  two  sinuses  developed  from 
a  cellula  frontalis,  medial  to  the  processus  uncinatus,  while  the  lateral  one  de- 
veloped from  the  infundibulum.  1,  Probe  through  the  ostium  of  the  medial 
sinus  frontalis,  the  ostium  being  anterior  to  the  cellula  frontalis  shown  in 
illustration;  S.front.,  sinus  frontalis;  Cel.front.,  cellula  frontalis;  Infund.eth., 
infundibulum  ethmoidale;  C.med.,  concha  media;  Ost.max.,  ostium  maxillare; 
C.inf.,  concha  inferior;  S.max.,  sinus  maxillaris;  N.infraorb.,  nervus  infra- 
orbitalis;  Proc.unc,  processus  uncinatus;  B.eth.,  bulla  ethmoidalis  (extreme 
anterior  portion) ;  Cr.graZ.,  crista  galli. 


THE    SINUS   FRONTALIS  145 

attached,  the  following  were  the  five  ways  in  which  develop- 
ment of  the  sinus  frontalis  occurred  and  the  percentage  of 
each  variety: 

1.  By  the  extension  of  one  of  the  cellulse  front  ales  in  41 
per  cent,  of  cases.  Such  development  is  shown  in  Figs. 
21,  23,  36,  41,  45,  47,  and  51.  The  development  of  the 
cellulae  frontales,  the  variations  in  their  number,  and  the 
irregularities  in  the  degree  of  prominence  attained  by  the 
conchse  frontales  were  considered  on  pages  46  and  53. 

2.  By  the  extension  of  the  recessus  conchalis — no  cellulae 
frontales  being  demonstrable — in  18.4  per  cent,  of  cases. 
Figs.  38,  43,  and  48  show  this  type  of  development.  In  this 
class  of  cases  the  conchse  frontales  have  either  failed  to  de- 
velop or  else  were  represented  by  such  slight  folds  that  they 
were  completely  resorbed  during  the  expansion  of  the  recessus 
conchalis. 

3.  By  the  extension  of  a  cellula  ethmoidalis  anterior 
having  its  origin  from  the  suprabullar  furrow,  in  1  per  cent, 
of  cases.     Such  development  is  distinctly  shown  in  Fig.  33. 

4.  By  the  direct  extension  of  the  infundibulum  ethmoidale, 
in  15.6  per  cent,  of  cases.     (See  Figs.  35  and  56.) 

5.  By  the  extension  of  one  of  the  cellulae  infundibulares 
in  24  per  cent,  of  cases.  Variations  in  this  type  of  origin 
are  shown  in  Figs.  28,  39,  49,  and  55. 

Summarizing  the  above  classification  of  origins,  we  find 
that  sinus  frontales  developing  by  the  first  three  methods — - 
a  total  of  60.4  per  cent,  of  the  cases  in  this  series — communi- 
cate with  the  meatus  medius  without  communicating  with 
the  infundibulum  ethmoidale.  Sinuses  which  develop  by 
the  fourth  and  fifth  methods,  however, — a  total  of  39.6  per 
cent,  of  the  cases  in  this  series, — communicate  with  the 

10 


146  THE   NASAL   ACCESSORY   SINUSES   IN  MAN 

meatus  medius  via  the  infundibulum  and  the  hiatus  semi- 
lunaris. Thus  in  these  cases  there  is  a  close  relationship 
between  the  sinus  frontales  and  the  sinus  maxillares,  since 
the  ostium  maxillare  in  all  cases  is  situated  in  the  infero- 
lateral  wall  of  the  infundibulum. 


SUPERNUMERARY  SINUS  FRONTALES 

Ordinarily  only  one  frontal  sinus  develops  on  each  side, 
but  in  a  few  instances  supernumerary  sinuses  are  found. 
The  term  supernumerary  sinuses  must  not  be  used  in  describ- 
ing sinuses  incompletely  divided  by  a  partial  septum  or 
septa,  but  is  restricted  to  cases  in  which  more  than  one 
distinct  process  of  pneumatization  from  either  lateral  nasal 
wall  develops  sufficiently  to  invade  the  vertical  portion  of  the 
frontal  bone — the  sinuses  being  separated  by  a  complete 
septum  and  having  independent  ostia. 

It  would  be  possible  to  have  supernumerary  sinuses  de- 
velop by  extensions  from  two  cellulse  infundibulares,  from 
two  cellulse  frontales,  or  from  any  combination  of  the  above- 
described  five  routes  of  development  of  sinus  frontales. 

In  101  cases  (202  frontal  areas)  having  mucosa  attached, 
we  found  two  cases  showing  the  presence  of  two  frontal 
sinuses  on  each  side,  and  three  cases  which  had  two  sinuses 
on  one  side  and  the  usual  one  sinus  on  the  other  side.  Thus 
of  the  202  frontal  areas,  7  of  them  had  double  sinuses.  In 
4  of  these  instances  the  double  sinuses  were  on  the  right  side, 
and  in  3  on  the  left.  The  ways  in  which  these  7  double 
sinuses  originated  were  as  follows: 

1.  By  the  extension  of  two  cells  medial  to  the  processus 
uncinatus  (cellulae  frontales)  in  three  instances  (Fig.  36). 


THE    SINUS   FRONTALIS 


147 


I 


S.  1  rorvt. 


Fig.  53. — Specimen  Twenty-one  Years,  Six  Months,  and  Twenty-nine 
Days  Old.  (Series  D,  No.  91.) 
Sagittal  section,  1.5  mm.  to  the  left  of  median  line.  Anterior  portion  of 
concha  media  has  been  removed  to  show  the  relations  of  structures  forming  the 
lateral  nasal  wall.  1,  Probe  through  ostium  frontale;  2,  probe  through  ostium 
sphenoidale;  S.front.,  sinus  frontalis;  H.semi.,  hiatus  semilunaris;  Proc.unc, 
processus  uncinatus;  C.inf.,  concha  inferior;  Ost.tub.aud.,  ostium  pharyngeum 
tubse  auditivse;  Hypoph.,  hypophysis;  C.sup.,  concha  superior;  C.med., 
concha  media;  Fis.supra.,  fissura  suprabullaris;  B.eth.,  bulla  ethmoidalis. 


THE    SINUS   FRONTALIS 


149 


S  .  f  r  o  ry.t 


Ce.l.i.rLtuad 


Cel.eth-.aLn-t. 


Cel.etK.post. 


lafuad.eth 
Duct.  rta.  Iq-c  f 


For.  rotuaclum. 


Fig.  54. — Specimen  Twenty-two  Years,  Six  Months,  and  Eleven  Days 
Old.  (Series  D,  No.  93.) 
Lateral  portions  of  the  frontal,  ethmoidal,  maxillary,  and  sphenoidal  areas 
have  been  removed  to  show  the  extent  and  relations  of  the  sinuses.  Note 
that  two  ostia  maxillaria  are  present,  both  communicating  with  theinfundib- 
ulum  ethmoidale.  (This  is  the  only  instance  of  this  kind  found  in  the  entire 
series.)  Cel.eth.ant.,  Cellulse  ethmoidales  anterior;  Cel.eth.post.,  cellulse  eth- 
moidales  posterior;  S.sph.,  sinus  sphenoidaHs;  For.rotundum,  medial  wall  of 
foramen  rotundum;  S.max.,  sinus  maxillaris;  Ost.max.{b),  ostium  maxillare; 
Ost.max.  (a),  duplication  of  ostium  maxillare;  Duct.na.lacr.,  ductus  naso- 
lacrimalis;  Infund.eth.,  infundibulum  ethmoidale;  Cel.infund.,  cellulse  in- 
fundibulares;  S. front.,  sinus  frontahs. 


THE    SINUS   FRONTALIS 


151 


S.troat. 


Ost.lro  n.t 


lalun.cl.Gtl' 
"Duct.aa..lacCT. 


S.n-ia-x: 


Fos.  CA 


Gaag.se 


A.,  car.  in.  t. 
Tub.a.ud. 


Lev.rri,.la.t. 


Fig.  55. — Specimen  Twenty-three  Years,  Seven  Months,  and  Thirteen 

Days  Old.     Lateral  View  of  Frontal,  Ethmoidal,  Maxillary,  and  a 

Portion  of  the  Sphenoidal  Areas.     (Series  D,  No.  94.) 

The  dotted  line  outlines  the  extent  of  the  sinus  sphenoidalis.     The  sinus 

sphenoidalis  and  the  sinus  maxillaris  are  both  unusually  small  for  an  adult. 

(Compare  with  preceding  figures.)     Note  also  the  unusually  large  fossa  canina. 

The  sinus  frontalis  developed  from  an  infundibular  cell.     Cel.eth.ant.,  Cellulae 

ethmoidales    anterior;     Cel.eth.post.,    cellulae    ethmoidales    posterior;    S.sph., 

sinus  sphenoidalis;  N. optic,  nervus  opticus;  A.car.int.,  arteria  carotis  interna; 

N.abduc,  nervus  abducens;   Gang.semi.,  ganglion  semilunare;    Tub.aud.,  tuba 

auditiva;     Lam.lat.,   lamina   lateralis   processus   pterygoidei;     Fos.ca.,   fossa 

canina;    Duct.na.lacr.,  ductus  nasolacrimalis;    Infund.eth.,  infundibulum  eth- 

moidale;  Ost.front.,  ostium  frontale;  S.front.,  sinus  frontaUs. 


THE    SINUS    FRONTALIS 


153 


B.eth.. 

C.med.Ccut  sur\s>.c^e) 
Ld-rrv.  crub. 
C-.sup. 

C.  swpr.  1. 
I      ,a. 


Sella,  turcica 


Proc.unc, 
Proc.tront.max 


cUvus 


For.spK,.pal. 
Ld-n-v  med. 


OS   pdLl. 


Fig.  56. — Specimen  Thirty-five  Years  Old.  Sagittal  Section  from  Which 
THE  Soft  Parts  Had  Been  Removed  by  Maceration.  (Series  E,  No.  5.) 
Concha  nasalis  media  has  been  removed  to  allow  a  better  view  of  the  proc- 
essus uncinatus  and  the  bulla  ethmoidalis.  The  sinus  frontalis  developed 
from  an  infundibular  cell.  1.,  Probe  through  ostium  frontale;  2.,  probe 
through  ostium  sphenoidale;  B.eth.,  bulla  ethmoidalis;  C.med.,  concha  media 
(cut  surf  ace) ;  Lam. cn6.,  lamina  cribrosa;  Cswp.,  concha  superior;  C.supr.I, 
concha  suprema  I;  For.sph.pal.,  foramen  sphenopalatinum ;  Lam.med., 
lamina  medialis  processus  pterygoidei;  Os  pal.,  pars  perpendicularis  ossis 
palatina;  C.inf.,  concha  inferior;  Proc.eth.,  processus  ethmoidalis  conchse 
nasalis  inferior;  Os  lacr.,  os  lacrimal;  Proc. front. max.,  processus  frontalis 
maxillae;  Proc.unc,  processus  uncinatus;  H.semi.,  hiatus  semilunaris;  Ag.na., 
agger  nasi;  S. front.,  sinus  frontalis. 


THE    SINUS   FRONTALIS 


155 


17    Ife       15    14 


Fig.  57. — Specimen  Thirty-eight  Years  Old.  Horizontal  Section  from 
Which  the  Soft  Parts  Had  Been  Removed  by  Maceration.  (Series 
E,  No.  15.) 

Plane  of  section  is  9  mm.  inferior  to  the  level  of  nasion,  or  4  mm.  inferior  to 
the  level  of  the  sutura  zygomaticofrontalis.  1,  Os  nasale;  2,  lamina  per- 
pendicularis  ossis  ethmoidalis;  3,  infundibulum  ethmoidale;  4,  cellulse  eth- 
moidales  anterior;  5,  lamina  papyracea  ossis  ethmoidalis;  6,  sulcus  infra- 
orbitalis;  7,  cellula  ethmoidalis  posterior;  8,  processus  orbitalis  ossis  palatini; 
9,  fissura  orbitalis  inferior;  10,  fissura  orbitalis  superior;  11,  foramen  opticum 
(inferior  surface);  12,  sinus  sphenoidalis;  13,  sella  turcica;  14,  foramen 
lacerum;  15,  foramen  rotundum;  16,  foramen  ovale;  17,  foramen  spinosum; 
18,  cellulse  ethmoidales  posterior;  19,  os  zygomaticum;  20,  facies  orbitalis 
maxillae;  21,  cellulse  ethmoidales  anterior;  22,  os  lacrimale;  23,  ductus  naso- 
lacrimalis;  klf.,  infundibulum  ethmoidale. 


THE    SINUS    FRONTALIS  157 

2.  By  the  extension  of  two  cells  lateral  to  the  processus 
uncinatus  (cellulse  infundibulares)  in  two  instances. 

3.  By  the  extension  of  an  infundibular  cell  and  the  direct 
extension  of  the  infundibulum  ethmoidale  in  one  instance. 

4.  By  the  extension  of  one  of  the  cellulse  frontales  and  the 
direct  extension  of  the  infundibulum  ethmoidale  in  one 
instance  (Fig.  52). 

THE  FORM  AND  BOUNDARIES  OF  THE  SINUS  FRONTALIS 
The  shapes  of  the  frontal  sinuses,  as  well  as  the  extent 
of  their  pneumatization,  show  a  wide  variation  in  the  differ- 
ent specimens  of  approximately  the  same  age.  In  average 
cases,  however,  sinuses  which  have  not  extended  into  the 
vertical  portion  of  the  frontal  bone  (infantile  types  of  sinuses) 
are  rather  ovoid  in  outline  (Figs.  21,  24,  27,  33,  and  36). 
When  pneumatization  has  extended  into  the  vertical  portion 
of  the  bone  (Figs.  49,  51,  53,  55,  and  56),  the  outline  of  the 
average  sinus  resembles  somewhat  a  three-sided  pyramid — 
as  described  by  Boege  and  by  Miloslawski  in  their  studies 
of  adult  sinuses.  Boege  found,  in  his  study  of  the  frontal 
sinuses  in  203  adult  macerated  skulls,  that  in  4.9  per  cent,  of 
cases  the  sinuses  on  both  sides  failed  in  their  superior  de- 
velopment to  reach  the  level  of  the  supra-orbital  margins; 
while  in  4.4  per  cent,  of  cases  the  right  sinus  alone,  and  in  2.5 
per  cent,  of  cases  the  left  sinus  alone,  failed  to  reach  a  height 
equal  to  that  of  the  supra-orbital  margin.  The  average 
diameters  of  the  frontal  sinuses  as  found  in  Boege's  203 
cases  are  23.6  mm.  laterally,  20.8  mm.  supero-inferiorly,  and 
16.1  mm.  anteroposteriorly.  The  average  diameters  of  de- 
veloping sinuses  as  found  in  the  various  ages  in  this  series 
are  given  in  the  table  on  pp.  134  and  135. 


158  THE   NASAL  ACCESSORY   SINUSES   IN   MAN 

The  anterior  wall  of  the  fully  developed  sinus  is  formed  by 
the  anterior  plate  of  the  vertical  portion  of  the  frontal  bone. 
This  is  the  thickest  of  the  sinus  walls,  different  specimens 
varying  from  1  to  8  mm.,  but  averaging  in  adult  cases  2.5 
mm.  in  thickness.  The  thicker  walls  contain  considerable 
diploe.  All  observers  agree  that  the  prominence  of  the 
superciliary  ridges  bears  no  constant  relationship  to  the  size 
of  the  sinuses  found  beneath  them. 

The  posterior  wall  of  the  fully  developed  sinus  is  formed 
by  a  part  of  the  posterior  plate  of  the  vertical  portion  of  the 
frontal  bone  and  also,  in  some  cases,  by  a  part  of  the  hori- 
zontal portion.  This  wall  is  composed  almost  entirely  of 
compact  bone  and  averages  1.2  mm.  in  thickness. 

The  medial  wall  is  formed  by  the  septum  front  ale,  which 
frequently  shows  deviations  toward  one  side  or  the  other. 
The  percentage  of  cases  showing  deviations  toward  the  right 
and  the  percentage  toward  the  left  are  approximately  equal. 
In  no  instance  was  the  septum  frontale  found  to  be  incom- 
plete. In  average  adult  cases  its  thickness  varies  from  0.5 
to  1  mm. 

The  floor  of  the  fully  developed  sinus  is  usually  quite 
uneven.  Laterally  it  is  formed  by  the  orbital  roof,  while 
medially  it  overlies  the  anterior  ethmoidal  cells.  In  the 
posteromedial  portion  of  the  floor  is  the  ostium  frontale, 
which  is  usually  situated  in  the  most  dependent  portion  of 
the  sinus  (Figs.  28,  33,  45,  and  52),  but  is  not  invariably 
so^an  antero-inferior  recess  sometimes  being  on  a  lower 
plane  (Figs.  35  and  49).  The  average  diameters  and  levels 
of  the  ostia,  as  found  in  the  various  ages,  are  given  in  the 
table  on  pp.  134-5.  Irregularities  in  the  floor  of  the  sinus, 
due  to  underlying  anterior  ethmoidal  cells,  were  considered 
on  pp.  54  and  63. 


THE    SINUS    FRONTALIS  159 

A  ''ductus  nasofrontalis "  is  mentioned  by  many  writers, 
but  we  have  seldom  found  one  distinctly  demonstrable.  In 
the  vast  majority  of  cases  the  ostium  frontale  communicates 
directly  with  a  frontal  cell,  with  the  recessus  conchalis, 
with  the  infundibulum  ethmoidale,  or  with  an  infundibular 
cell  without  the  interposition  of  a  duct  (Figs.  35,  36,  38, 
51,  53,  55,  56).  In  some  very  few  instances,  however, 
where  the  sinus  has  developed  either  from  an  infundibular 
cell  or  from  a  frontal  cell  which  is  pressed  upon  and  narrowed 
by  the  partially  surrounding  cells  of  that  group,  the  resulting 
constriction  may  resemble  a  duct,  as  in  Fig.  39,  and  in  the 
right  medial  sinus  in  Fig.  52.  In  the  latter  figure  the  probe 
shows  the  position  of  the  narrowed  cell,  or  so-called  ductus 
nasofrontalis. 

The  freedom  of  communication  between  the  sinus  frontalis 
and  the  meatus  medius  is  often  interfered  with  by  an  en- 
larged concha  media,  which  narrows  the  opening  into  the 
recessus  conchalis,  or  which  comes  into  close  contact  with 
the  hiatus  semilunaris.  In  other  cases  a  malposed  small  or 
narrowed  concha  may  produce  a  similar  result.  In  Fig.  42 
the  influence  of  pressure  from  a  septal  ridge,  as  exerted  upon 
the  concha  media,  and  the  narrowing  of  the  hiatus  semilunaris 
and  the  infundibulum  ethmoidale,  which  results  from  the 
change  in  the  degree  of  medial  inclination  of  the  processus 
uncinatus,  is  clearly  shown.  Slight  swelling  in  such  a  case 
would  completely  occlude  the  communication  between  the 
sinus  frontalis  and  the  meatus  medius. 


THE  SINUS  SPHENOIDALIS 

The  sinus  sphenoidalis  differs  in  its  early  development 
from  the  other  accessory  sinuses  in  that  the  primitive  sinus 
does  not  have  its  origin  from  one  of  the  furrows  situated  on 
the  lateral  nasal  wall,  but  develops  as  an  invagination  ex- 
tending from  the  posterosuperior  portion  of  the  recessus 
sphenoe  thmoidalis . 

In  the  narrowed  posterosuperior  portion  of  the  recessus 
sphenoethmoidalis  there  is  demonstrable  in  sixty-five-day 
embryos  an  invagination  of  the  mucosa  extending  into  the 
posterior  portion  of  the  nasal  capsule  (Fig.  8).  The  site 
of  this  primitive  invagination  persists  as  the  ostium  sphenoid- 
ale. Embryos  of  eighty-five  to  one  hundred  days  show  the 
development  into  the  nasal  capsule  more  distinctly  (Fig.  11), 
the  advancement  of  the  pouching  process  being  most  fre- 
quent in  a  postero-inferior  and  slightly  lateral  direction. 
The  primitive  sphenoidal  sinuses  thus  come  to  lie  posterior 
to  the  nasal  capsule  and  anterolateral  to  the  body  of  the 
sphenoid  bone  (Figs.  15  and  16).  In  that  portion  of  the 
nasal  capsule  which  forms  the  antero-inferior  wall  of  the 
primitive  sinus  there  develops  an  ossification  center  for  the 
concha  sphenoidalis  or  ossiculum  Bertini.  Ossification  of 
this  concha  sphenoidalis  is  in  many  instances  well  advanced 
in  term  fetuses  and  infants  (Fig.  18),  but  it  is  not  until  the 
second  or  third  year  that  this  bone  becomes  firmly  attached 
to  and  continuous  with  the  body  of  the  sphenoid. 

The   extent   of   development   of  the   sinus   sphenoidales 

160 


THE    SINUS   SPHENOID ALIS  161 

during  childhood  has  evidently  been  underestimated. 
Many  writers  quote  Toldt^s  statement,  that  in  the  develop- 
ment of  the  sinus  sphenoidalis  the  resorption  process  is 
noticeable  in  the  third  year,  reaches  the  sphenoid  bone  in 
the  sixth  or  seventh  year,  and  in  the  eighth  to  the  tenth  year 
really  becomes  a  cavity  in  the  sphenoid  bone.  The  scarcity 
of  anatomic  material  showing  the  conditions  present  dur- 
ing childhood  is  probably  responsible  for  such  conclusions. 
Figs.  15,  16,  18,  22,  27,  29,  and  31  show  approximately  the 
average  development  as  found  in  the  given  ages  in  this 
series,  and  the  extent  of  pneumatization  is  seen  to  be  much 
greater  than  in  the  cases  observed  by  Toldt. 

The  average  diameters  of  the  sinus  sphenoidales  as  found 
in  the  specimens  of  the  various  ages  studied  in  this  series 
are  given  in  the  following  table.  The  average  distance  from 
the  superior  border  of  the  ostia  sphenoidalia  to  the  level  of 
the  cribriform  plate  of  the  ethmoid,  the  average  diameters 
of  the  ostia,  and  the  thickness  of  the  sphenoidal  septum  are 
also  given.     All  measurements  are  in  millimeters. 

The  marked  tendency  of  the  sinus  sphenoidalis  to  develop 
posterolaterally  more  rapidly  than  it  does  directly  pos- 
teriorly (Fig.  22)  is  such  that  in  the  average  case  the  lateral 
wall  of  the  sinus  becomes  quite  thin  (one  millimeter  or  less 
in  the  thinest  portion)  by  the  end  of  the  second  or  during 
the  third  year,  while  the  septum  sphenoidale  still  remains 
relatively  thick — first  reaching  an  average  of  one  millimeter 
or  less  in  the  ninth  year.  (See  table  p.  162.)  Thus  this 
early  posterolateral  resorption  of  the  osseous  wall  soon  brings 
the  sinus  into  close  relation  to  those  cranial  nerves  which 
pass  just  lateral  to  the  body  of  the  sphenoid  (Figs.  21,  30, 

32,  39,  45,  47,  50,  and  55),  and  shows  an  anatomic  basis  for 
11 


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163 


164  THE   NASAL   ACCESSORY   SINUSES   IN   MAN 

the  clinical  observations  of  Dr.  Greenfield  Sluder,  of  St. 
Louis,  regarding  neuralgias  from  irritations  of  the  fifth 
nerve  by  infectious  processes  in  the  sinus  sphenoidalis — such 
irritation  in  some  reported  instances  having  first  occurred 
in  early  childhood. 

In  all  cases  in  this  series  one  sinus  sphenoidalis  was  found 
on  each  side,  and  in  no  instance  was  more  than  the  one  pres- 
ent. The  septum  sphenoidale  was  in  all  cases  complete. 
The  position  of  the  septum  was  usually  vertical  and  median 
in  the  anterior  portion,  but  deviating  slightly  from  these 
planes  posteriorly.  In  some  instances,  however,  the  in- 
equality in  the  rate  of  resorption  had  been  sufficient  to  pro- 
duce a  more  marked  deviation  of  the  septum,  even  to  an 
extent  which  made  the  septum  form  the  posteromedial 
wall  of  the  smaller  sinus — a  process  similar  to  that  described 
when  considering  deviations  of  the  septum  frontale. 

The  extent  of  sphenoidal  pneumatization,  like  that  of  all 
other  nasal  accessory  sinuses,  may  show  wide  variations  in 
specimens  of  approximately  the  same  age.  The  develop- 
ment during  childhood  may  be  slow,  as  is  shown  in  Figs. 
32,  34,  and  36,  and  marked  deficiency  in  resorption  may 
persist  in  adult  specimens  (Fig.  55).  The  sinus  shown  in 
Fig.  56  may  be  taken  as  the  form  to  illustrate  approximately 
the  average  adult  type.  In  many  instances,  however,  the 
sinuses  not  only  fill  the  body  of  the  sphenoid,  but  may  ex- 
tend far  into  the  clivus,  or  recesses  may  develop  into  the 
processus  pterygoideus  (Figs.  45,  47,  and  54),  into  the  greater 
or  the  lesser  wings  of  the  sphenoid,  or,  in  some  instances, 
into  the  orbital  process  of  the  palate  bone.  (Pneumatiza- 
tion of  the  orbital  process  of  the  palate  bone,  however,  was 
found  to  be  more  frequently  produced  by  the  extension  of  a 


THE    SINUS    SPHENOID ALIS  165 

recess  from  the  most  posterior  of  the  ethmoidal  cells.)  The 
extent  of  pneumatization  of  the  sphenoid  bears  in  no  way 
a  constant  relationship  to  the  size  of  the  other  accessory 
nasal  sinuses,  nor  was  there  found  to  be  any  definite  propor- 
tion between  the  size  of  the  sphenoidal  sinus  and  the  size 
of  the  nasopharynx.  In  average  cases  the  rate  of  resorption 
of  the  body  of  the  sphenoid  is  such  that  by  the  eighth  to 
the  tenth  year  the  posterosuperior  portion  of  the  sinus  lies 
beneath  the  anterior  portion  of  the  sella  turcica  (Fig.  38), 
and  by  the  fifteenth  year  is  usually  separated  from  the 
hypophysis  by  a  very  thin  lamina  of  compact  bone  (Fig.  46) . 
Anterosuperiorly,  the  sinus  sphenoidalis  is  in  close  relation 
to  the  most  posterior  of  the  ethmoidal  cells  (Figs.  28,  43, 
49,  54,  and  57),  but  in  no  case  was  there  a  communication 
between  the  sinus  and  such  cells.  Deficiencies  in  the  lateral 
osseous  wall  of  the  sinus  have  been  described  by  Zuckerkandl 
and  by  Craig,  but  in  this  series  we  have  found  no  such  condi- 
tions present. 

Irregularities  in  the  resorption  of  the  bone  may  leave 
ridges  similar  in  character  to  those  found  in  the  frontal  and 
in  the  maxillary  sinuses.  Varying  types  of  such  ridges  are 
seen  in  Figs.  31,  46,  48,  54,  56,  and  57.  In  addition  to  these 
ridges,  when  there  is  a  recess  extending  well  into  the  ptery- 
goid process,  there  is  on  the  floor  of  the  sinus  a  distinct 
ridge  (Figs.  45  and  47)  which  overlies  the  nervus  canalis 
pterygoid ei  (Vidii). 


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INDEX 


Agger  nasi,  26,  53 

pneumatization  of,  63 
Anatomic  material  used,  11-14 


Bulla  ethmoidalis,  26,  35,  63,  64 
frontalis,  54 


Capsule,  nasal,  19,  20,  25 
Cellulse  conchales,  78 
ethmoidales,  44 
anterior,  46 
classification  of,  44 
development  of,  45 
ostia  of,  77 
posterior,  77 
frontales,  53 
infundibulares,  46,  54 
Choanae,  primitive,  20 
Conchae  frontales,  53 

nasales,  early  development  of,  20, 
25,  35,  36 
nomenclature  of,  36 
number  of,  35,  36,  43 
sphenoidales,  160 


Development,  early,  of  nasal  conchse, 
20,  25,  35,  36 
of  nasal  areas,  19 
Ductus  nasofrontalis,  159 


Ethmoid  cells,  44 
anterior,  46 
classification  of,  44 


Ethmoid  cells,  development  of,  45 
ostia  of,  77 
posterior,  77 
fold,  primitive,  25 
Ethmoidal  bulla,  26,  35,  63,  64 

infundibulum,  35,  54,  64,  79,  110, 
146,  159 


Frontal  bulla,  54 

cells,  53 

conchae,  53 

ostium,  133,  134,  135,  159 

septum,  136 

sinus,  132 

average  measurements  of,    134, 

135 
form  and  boundaries  of,  136,  157 
routes  of  development,  132,  145 
supernumerary,  146,  157 
walls  of,  133,  158 


Hiatus  semilunaris,  35,  64,  110,  159 


Infundibular  cells,  46,  54 

recess,  46,  64,  132 
Infundibulum  ethmoidale,  35,  54,  64, 

79,  110,  146,  159 


Material  (anatomic)  used,  11-14 
Maxillary  ostium,  79,  109,  146 

accessory,  112,  113 

duplication  of,  110,  111 
sinus,  79 

average  measurements  of,  80,  81 


171 


172 


INDEX 


Maxillary  sinus,  double,  131 
form  of,  82 

incomplete  septa  in,  130 
relation  to  teeth,  79,  129,  130 
walls  of,  109,  114,  129 


Nasal  areas,  development  of,  19 
capsule,  19,  20,  25 
conchae,  early  development,  20,  25, 
35,  36 
nomenclature  of,  36 
number  of,  35,  36,  43 
pits,  19 
septum,  19 
Nasofrontal  duct,  159 


Os  palatinum,  pneumatization  of,  164 
Ostium  frontale,  133,  134,  135,  159 
maxillare,  79,  109,  146 
accessorium,  112,  113 
duplication  of,  110,  111 
sphenoidale,  160,  161 


Pneumatization  of  agger  nasi,  63 

of  OS  palatinum,  164 
Processus  uncinatus,  26,  53,  64,  109, 

110,  159 


Recessus  conchahs,  46,  64,  132 
infundibularis,  46,  64,  132  , 


Semilunar  hiatus,  35,  64,  110,  159 
Septum  frontale,  136 
nasi,  19 


Septum  sphenoidale,  164 
Sinus  frontalis,  132 

average   measurements   of,    134, 

135 
form  and  boundaries  of,  136,  157 
routes  of  development,  132,  145 
supernumerary,  146,  157 
walls  of,  133,  158 
maxillaris,  79 

average  measurements  of,  80,  81 
double,  131 
form  of,  82 

incomplete  septa  in,  130 
relation  to  teeth,  79,  129,  130 
walls  of,  109,  114,  129 
sphenoidaUs,  160 

average   measurements    of,    161, 

162,  163 
forms  of,  164 
ridges  in,  165 
Specimens,   method  of  obtaining,  at 
postmortem  examination,  15 
used  in  preparing,  16,  17 
Sphenoid  conchae,  160 
ostium,  160,  161 
septum,  164 
sinus,  160 

average  measurements  of,    161, 

162,  163 
forms  of,  164 
ridges  in,  165 


Teeth,  relation  of,  to  sinus  maxillaris, 
79,  129,  130 


Uncinate  process,  26,  53,    64,   109, 
110,  159 


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